Applied Sciences Assignment 1

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Behavior Analysis in Practice (2019) 12:557–575 https://doi.org/10.1007/s40617-018-00313-6

RESEARCH ARTICLE

Behavior Analysts’ Training and Practices Regarding Cultural Diversity: the Case for Culturally Competent Care

Lauren Beaulieu1,2 & Joshua Addington1

& Daniel Almeida2

Published online: 7 December 2018 # Association for Behavior Analysis International 2018

Abstract The U.S. Census Bureau predicts that by 2044, the United States will become a majority minority nation, meaning no group will have a majority portion of the total population (Colby & Ortman, 2014). Therefore, training on working effectively with individuals from diverse backgrounds is critical. We surveyed Board Certified Behavior Analysts (BCBAs) to assess the amount of training they received during their coursework, fieldwork or practicum, employer training, and continuing education on working with people from diverse backgrounds. In addition, we assessed whether BCBAs thought training on this topic was important, how skilled they thought they were in this area, and whether behavior-analytic course instructors included material on cultural diversity in their courses. The majority of respondents reported that training on working with individuals from diverse backgrounds is very or extremely important. Interestingly, although the majority of respondents reported they felt moderately or extremely comfortable and were moderately or extremely skilled at working with individuals from diverse backgrounds, the majority of respondents reported having little or no training in this area. We discuss the implications of these results for the field of applied behavior analysis and future directions.

Keywords Cultural assessment . Cultural awareness . Cultural sensitivity . Diversity

The U.S. Census Bureau predicts that by 2044, the United States will become a majority minority nation, which means no specific demographic category will have a majority portion of the total population (Colby & Ortman, 2014). The diversity of children in the United States is increasing at an even faster rate, and projections are that by 2020, the population of chil- dren in the United States will be majority minority, and by 2060, one in five individuals will be foreign born (Colby & Ortman, 2014). Providing health care to individuals from di- verse backgrounds poses many challenges related to the ac- ceptability of procedures, appropriateness of procedures, and adherence to procedures (Betancourt, Green, Carrillo, & Owusu Ananeh-Firempong, 2016; Britton, 2004).

Skinner (1971) loosely defines culture as the various con- tingencies of reinforcement prevailing in the environment in which we are born and that we experience throughout our

* Lauren Beaulieu [email protected]

1 Department of Psychology, Florida Institute of Technology, Melbourne, FL, USA

2 Present address: Newton Public Schools, Newton, MA 02460, USA

lives. The contingencies can be difficult to identify, particular- ly social contingencies when the reinforcers are related to social values and ideas that evoke the behavior. An individ- ual’s culture offers distinct contingencies that shape and effect behavior, and one’s culture directly relates to one’s opinions and perceptions regarding socially appropriate behavior (Glenn, 2004; Skinner, 1971).

The behaviors that embody a culture include the way we socialize with others, the language we use and the specific words within a language, our religion or lack of religion, the way we solve problems and make decisions, the gestures we use, the things we eat, the clothes we wear, gender roles, the way we parent, our values, our beliefs, and our priorities. All of our operant behavior, and even some of our respondent behavior, is affected in part by our culture. For example, the sight of a tarantula might elicit a conditioned startle reflex with an American, whereas a tarantula, considered a delicacy to many people in Cambodia, might elicit conditioned salivation when seen by a Cambodian. Because culture underlies much of our behavior, understanding the differences in cultures and how to work effectively with individuals from diverse back- grounds is critical when working in applied settings.

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Cultural variables can include socioeconomic status, race, ethnicity, age, nationality, disability, gender, sexual orienta- tion, and religion. Ignored or unidentified cultural variables may become barriers to the delivery of effective treatment (Betancourt et al., 2016; Kodjo, 2009). Culture intersects with behavior analysis in several ways. From the moment a health care professional accepts a client, cultural variables are oper- ating that might have favorable or detrimental effects with respect to building rapport with a family (Kodjo, 2009; Parette & Huer, 2002). These effects could lead to a family accepting services or early termination, and potentially turning a family away from behavior analysis altogether; however, research on the explicit effects of cultural variables is limited. Cultural variables may also underlie how readily a client ac- cepts diagnosis, clients’ preferences for specific targets (e.g., social targets vs. academic targets), and the types of treatments a client seeks out (Betancourt et al., 2016; Kodjo, 2009; Lo & Fung, 2003; Parette & Huer, 2002; Vandenberghe, 2008). The types of treatments we select are impacted by the value we place on Western science, and Western science can be viewed as a culture in itself (Kodjo, 2009; Parette & Huer, 2002). The extent to which we value Western science directly relates to how readily we accept or deny the argument for and benefit of evidence-based treatment. If a client or caregiver does not value Western science, the practitioner may find it difficult to obtain buy-in from the caregiver.

Communication—both vocal and gestural—might be one of the most relevant cultural variables related to developing and maintaining therapeutic relationships with clients and stakeholders. Some researchers assert that our cultural back- ground affects the way we interact with authority figures, which can affect assessment and treatment procedures (Kodjo, 2009; Parette & Huer, 2002). For example, many Asian cultures are more likely to use indirect communication and are less likely to explicitly disagree with an authority figure and instead will actively avoid conflict (Morris et al., 1998). In addition, gestures can have different meanings in different cultures. An individual from an Asian culture may appear to consent to a procedure (e.g., head nodding) even though he or she does not agree with the procedure but was instead head nodding to denote he or she heard the profession- al (Parette & Huer, 2002). Kowner (2002) found that Japanese individuals viewed communication with Westerners as un- pleasant. The Japanese participants also rated the Westerners’ communication styles to be similar to that of high-status Japanese, and the author posits that the Japanese participants may have rated communication with Westerners as unpleasant because the behaviors and gestures emitted by the Westerners—who were of equal status to the Japanese participants—were similar to a high-status Japanese person speaking with a low-status Japanese person. However, the results must be interpreted with caution as this study was a descriptive study and did not experimentally evaluate cultural

variables. Nonetheless, this study provides some evidence that interactions between cultures can be interpreted very differently across cultures.

Unfortunately, few behavioral studies have evaluated the effects of cultural variables on behavior, but the few that have been conducted have demonstrated notable results. One such study conducted by Lang et al. (2011) observed increases in challenging behavior and decreases in correct responding when instruction was delivered in the participant’s second language (English) and subsequent decreases in challenging behavior and increases in correct responding when instruction was delivered in the participant’s first language (Spanish). Similarly, Rispoli et al. (2011) evaluated the effects of the language of implementation of functional analysis (FA) con- ditions on the levels of problem behavior emitted by a partic- ipant from a Spanish-speaking home. The authors observed increases in problem behavior when the FA was conducted in English, thus demonstrating that the language used to imple- ment FA conditions can impact levels of problem behavior. These studies support the need to identify and consider lin- guistic backgrounds (i.e., cultural variables). However, in a review of the literature, Brodhead, Durán, and Bloom (2014) found only 6% of language studies in the Journal of Applied Behavior Analysis and 3% of language studies in The Analysis of Verbal Behavior disclosed cultural and linguistic backgrounds.

Cross (1989) asserts that cultural competence is a develop- mental process that encompasses the capacity to address the distinctive needs of populations whose cultures are different from the mainstream United States. Culture is always evolv- ing; therefore, becoming culturally competent is a lifelong endeavor that needs continuous improvement (Fong & Tanaka, 2013). Other helping professions are further ahead than behavior analysis with respect to cultural competence. The American Psychological Association (2008), the American Speech-Language-Hearing Association (2017), and the American Academy of Pediatrics (Britton, 2004) have task forces on diversity, training requirements, policy state- ments, and/or guidelines with respect to serving diverse pop- ulations, but the field of behavior analysis has yet to adopt a formal set of guidelines. Fong and Tanaka (2013) propose a comprehensive list of guidelines on cultural competence for the field of behavior analysis to consider. However, these guidelines have not been formally adopted by the Behavior Analyst Certification Board (BACB); therefore, many behav- ior analysts may not be aware of them.

Furthermore, some of our professional guidelines appear to be incongruent with incorporating cultural variables. One rather contentious example is whether behavior analysts should accept gifts (Witts, Brodhead, Adlington, & Barron, 2018). There is no consensus across areas of psychology; however, Simon (1992) asserts that although some therapists are fine with accepting gifts of small monetary value,

559 Behav Analysis Practice (2019) 12:557–575

compensation of one’s services should be received from the fee received from the patient and professional gratification from providing high-quality services. This stance appears to be echoed in behavior analysis by Bailey and Burch (2016), who state behavior analysts should not accept gifts of any kind. However, Hoop, DiPasquale, Hernandez, and Roberts (2008) provide a more culturally impartial discussion on the topic of receiving gifts. They discuss the importance of con- sidering the implications of refusing gifts during cross-cultural treatment but also warn of the potential issues of relaxing boundaries with those of different cultural backgrounds and how this could result in relaxing other boundaries as well. Unfortunately, there is no research with respect to how receiv- ing and giving gifts affects treatment (Hoop et al., 2008). However, to get a sense of how many behavior analysts accept gifts from clients, Witts et al. (2018) conducted a survey on this very topic. Of the 57 respondents, 40% reported they accepted gifts of small monetary value, 12% accepted gifts of moderate value, and 77% reported their clients would be offended if they refused the gifts. If behavior analysis wants to become more sensitive to cultural variables, it seems impor- tant to evaluate the effects of refusing all gifts on therapeutic relationships with people from cultures where refusing gifts is disrespectful and modify (if needed) our professional guide- lines to reflect a culturally sensitive model that allows for the delivery of effective treatment.

Another important variable that impacts the level of train- ing on cultural diversity is the coursework requirements for behavior analysts, which will be based on the BACB’s Fifth Edition Task List in the year 2022 (BACB, 2017b). The Fifth Edition Task List includes various principles and concepts of behavior and how these principles and concepts relate to the assessment and treatment of behavior. Although cultural di- versity is not included in the Fifth Edition Task List, there are components of the BACB’s Professional and Ethical Compliance Code for Behavior Analysts that relate to cultural diversity training. Specifically, guideline 1.05, Professional and Scientific Relationships (c), states,

Where differences of age, gender, race, culture, ethnic- ity, national origin, religion, sexual orientation, disabil- ity, language, or socioeconomic status significantly af- fect behavior analysts’ work concerning particular indi- viduals or groups, behavior analysts obtain the training, experience, consultation, and/or supervision necessary to ensure the competence of their services, or they make appropriate referrals. (BACB, 2017a, p. 5)

In other words, if practitioners are working with people from diverse backgrounds, they should be obtaining the necessary experience and training in this area, which raises the important question, are behavior analysts trained to work with individ- uals from diverse backgrounds and are there opportunities for

them to access this type of training? Kelly and Tincani (2013) asked a related question and surveyed 302 behavior analysts to identify how many received training in collaborating with other professionals. Although learning to collaborate with oth- er professionals is not identical to cultural diversity training, collaborating with other individuals involves learning how to work with others who are different from you or your back- ground. Sadly, they found that the majority of respondents received little to no training in working collaboratively with people from different professional backgrounds, which dem- onstrates a need for this type of training in behavior analysis.

Becoming culturally competent behavior analysts is critical if we want to deliver effective behavioral treatment and reduce the known disparity of health care to individuals from diverse backgrounds (Flores & Tomany-Korman, 2008). The purpose of our study was to answer the aforementioned questions. We conducted a survey to assess the extent of training Board Certified Behavior Analysts (BCBAs) received on working with individuals from diverse backgrounds, the opportunities for such trainings, the importance of cultural diversity train- ing, and the degree to which practitioners felt comfortable and skilled in this area. In addition, we assessed the implementa- tion of various practices related to the delivery of culturally competent care.

Method

Participants and Setting

Participants were recruited via an e-mail sent out through the BACB e-mail list. The e-mail was sent to 20,553 BCBA certificants (including those with the BCBA-D [Doctoral] des- ignation) worldwide and was completed by 707 respondents. Four respondents reported they were not BCBAs; therefore, their data were excluded from the analysis, and 703 respon- dents were included in the results. Demographic data of the participants are presented in Table 1. This study was approved by an institutional review board, and all participants were required to complete an informed consent to participate. The survey was completed online via the Qualtrics website (https://www.qualtrics.com).

Materials

The survey consisted of 40 multiple-choice questions (5-point Likert scale) and was hosted by Qualtrics. The survey includ- ed questions on the demographics of respondents; the impor- tance of receiving training on working with people from di- verse backgrounds; the comfort level and skill level of respon- dents regarding working with individuals from diverse back- grounds; and the amount of cultural diversity training respon- dents received via behavior-analytic coursework during their

560 Behav Analysis Practice (2019) 12:557–575

Table 1 Participant Demographics

Age N Percentage

Under 30 77

30–39 312

40–49 165

50–59 59

60–69 22

70–79 4

Greater than 80 0

Total 639

Gender

Female 531

Male 97

Nonbinary/third gender 6

Self-describe 0

Prefer not to say 4

Total 638

Race

White 554

African American 22

Asian 41

Native Hawaiian 3

American Indian 10

Self-describe 30

Total 660

Ethnicity

Hispanic 67

Non-Hispanic 544

Total 611

Current nationality

U.S. citizen 548

Dual citizen 25

Other 65

Total 638

Field of master’s degree

Applied behavior analysis 208

Behavior analysis 38

Psychology 127

Education 191

Other 75

Total 639

Field of PhD

No PhD 485

Applied behavior analysis 24

Behavior analysis 18

Psychology 32

Education 21

Other 31

Total 611

12

49

26

9

3

1

0

100

83

15

1

0

1

100

84

3

6

1

1

5

100

11

89

100

86

4

10

100

32

6

20

30

12

100

79

4

3

5

4

5

100

master’s and doctoral degrees, non-behavior-analytic coursework during their master’s and doctoral degrees, field- work or practicum during their master’s and doctoral degrees, continuing education, and employer training (see Appendix for exact survey questions). In addition, the survey included questions regarding whether the respondent considered vari- ous cultural variables (e.g., asked clients if they were reli- gious, if they had dietary preferences, or about their preferred forms of communication). These questions were selected based on a review of the literature on cultural competence (e.g., Carrillo, Green, & Betancourt, 1999; Tanaka-Matsumi, Seiden, & Lam, 1996). The survey also included three addi- tional questions for verified course sequence instructors that asked about the importance of training students to work with individuals from diverse backgrounds, the amount of material they included in their coursework, and the amount of material they included in their practicum or fieldwork. A complete list of survey questions is included in the Appendix.

Procedure

Participants were given 1 month to complete the survey and could only take the survey once. The 40-question survey took approximately 10 min to complete. Participants could stop the survey and complete it at any time during the 1 month. Approximately 2 weeks after the initial recruitment e-mail, a reminder e-mail was sent to all certificants reminding them about the survey. Participants received no compensation for completing the survey.

Results

Participant Demographics

Table 1 depicts the demographic information reported by the respondents. The majority of respondents were non-Hispanic (89%) White (84%) female (83%) U.S. citizens (86%) be- tween the ages of 30 and 39 (49%). Minorities made up 16% of respondents, with no single minority reaching above 6%. The majority of respondents had a master’s degree in applied behavior analysis (32%), followed by education (30%) and psychology (20%), and 21% of respondents had a PhD in psychology (5%), other (5%), applied behavior anal- ysis (4%), education (4%), or behavior analysis (3%).

Table 2 depicts the employment characteristics of the re- spondents. The majority of respondents worked in clients’ homes (32%), centers or clinics (22%), or public schools (20%), and respondents’ primary roles as BCBAs were as supervisors (45%) or practitioners (28%). Respondents pri- marily worked with individuals diagnosed with autism spec- trum disorder (68%), which was followed by working in spe- cial education (10%). The majority of respondents (57%)

561 Behav Analysis Practice (2019) 12:557–575

Table 2 Participant Employment and Education Characteristics backgrounds. In addition, the majority of respondents reported

Proportion of diverse clients N Percentage

Less than 10% 67 10 10%–19% 48 7 20%–29% 62 9 30%–39% 67 10 40%–49% 51 7 50%–59% 124 18 60%–69% 71 10 70%–79% 66 9 80%–89% 59 8 Greater than 90% 87 12 Total 702 100

Primary work setting Public school 130 20 Private school 39 6 Client’s home 205 32 Center/clinic 138 22 College/university 47 7 Residential facility 26 4 Hospital 5 1 Community 15 2 Other 36 6 Total 641 100

Primary role as a BCBA Practitioner (direct services) 181 28 Supervisor 290 45 Administrator 74 11 Lecturer/instructor 10 2 Professor/researcher 37 6 Other 49 8 Total 641 100

Population of primary work Autism spectrum disorder 433 68 Intellectual disability 56 8 Special education 66 10 Emotional or behavioral disorders 33 5 Mental health 12 2 General education 4 1 Brain injury 3 1 Typically developing 7 1 Gerontology 1 >1 Employees 4 >1 Child welfare 1 >1 Other 21 3 Total 641 100

reported that more than half of their clients were from diverse backgrounds.

Importance, Skill, and Training

Table 3 depicts the respondents’ comfort level and skill level with respect to working with individuals from diverse back- grounds, the importance of cultural diversity training, and the amount of training respondents received with respect to cul- tural diversity. The majority of respondents reported that train- ing on working with individuals from diverse backgrounds was extremely important (58%) or very important (30%), and they felt extremely comfortable (49%) or moderately comfortable (43%) working with individuals from diverse

being moderately skilled (63%) or extremely skilled (23%) at working with individuals from diverse backgrounds.

With respect to training and coursework on working with individuals from diverse backgrounds during the respondents’ master’s degrees, the majority of respondents reported their master’s degree behavior-analytic courses included a little (47%) or none at all (35%) material; their master’s degree non-behavioral courses included a little (41%), a moderate amount (23%), or none at all (18%) material; and their mas- ter’s degree hands-on training included none at all (39%) or a little (28%) material. With respect to training and coursework on working with individuals from diverse backgrounds during the respondents’ PhD degrees, the majority of respondents with a PhD reported their behavior-analytic courses for their PhD degree included none at all (32%) or a little (32%) ma- terial, and their non-behavioral courses for their PhD degree included a little (27%), a moderate amount (17%), or a great deal (18%) of material. Respondents reported their PhD de- gree hands-on training included none at all (31%), a little (26%), or a moderate amount (20%) of material.

With respect to employer trainings on working with indi- viduals from diverse backgrounds, the majority of respon- dents reported their employer provided none at all (42%) or a little (29%) training. In addition, the majority of respondents reported participating in none at all (40%) or a little (38%) continuing education opportunities related to cultural diversity and seeing a little (55%) or none at all (29%) continuing education opportunities on diversity at conferences or online continuing education opportunities.

The majority of respondents who were instructors of BACB- approved courses reported it was extremely important (57%) or very important (30%) to teach students to work with individuals from diverse backgrounds during their graduate studies, and re- spondents included a little (32%), a moderate amount (27%), a lot (15%), a great deal (13%) or none at all (13%) material in the courses they taught. The majority of respondents who taught practicum or fieldwork courses included a moderate amount (31%), a little (23%), or a great deal (21%) of material on work- ing with individuals from diverse backgrounds.

Culturally Competent Practices

Table 4 depicts practices related to delivering culturally competent care. The majority of respondents reported be- ing moderately (40%) or somewhat familiar (31%) with the process of delivering culturally competent care. With respect to culturally competent practices, the majority of respondents educated themselves on a client’s culture if the client immigrated from another country most times (32%), sometimes (28%), or every time (28%); however, the majority of respondents never (32%), rarely (25%), or sometimes (21%) asked their clients about their religious

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Table 3 Importance of and Training on Cultural Diversity Table 3 (continued)

Comfort level working with individuals from diverse N Percentage Comfort level working with individuals from diverse N Percentage backgrounds backgrounds

Extremely uncomfortable 10 1 Not applicable 24 18

Somewhat uncomfortable 12 2 Total 131 100

Neither comfortable or uncomfortable 36 5 Master’s hands-on training on diversity

Moderately comfortable 302 43 None at all 272 39

Extremely comfortable 342 49 A little 194 28

Total 702 100 A moderate amount 132 19

Skill level working with individuals from diverse backgrounds A lot 60 9

Not skilled 1 >1 A great deal 31 5

Slightly skilled 24 3 Total 689 100

Neither skilled or unskilled 71 10 PhD hands-on training on diversity

Moderately skilled 446 63 None at all 40 31

Extremely skilled 161 23 A little 34 26

Total 703 100 A moderate amount 26 20

Importance of cultural diversity training A lot 18 14

Not at all important 2 >1 A great deal 11 9

Slightly important 12 2 Total 129 100

Moderately important 66 9 Employer-offered training

Very important 212 30 None 281 42

Extremely important 411 58 A little 193 29

Total 702 100 A moderate amount 111 17

Master’s ABA coursework on diversity A lot 48 7

None at all 244 35 A great deal 34 5

A little 327 47 Total 667 100

A moderate amount 80 12 CE completed

A lot 21 3 None at all 271 40

A great deal 17 3 A little 255 38

Total 689 100 A moderate amount 101 15

Master’s non-ABA coursework on diversity A lot 26 4

None at all 99 18 A great deal 17 3

A little 234 41 Total 670 100

A moderate amount 132 23 Observed CE offerings on diversity

A lot 63 11 None at all 197 29

A great deal 40 7 A little 369 55

Not applicable 121 18 A moderate amount 86 13

Total 689 100 A lot 11 2

PhD ABA coursework on diversity A great deal 7 1

None at all 47 32 Total 670 100

A little 46 32 Importance of teaching diversity (instructors)

A moderate amount 34 23 Not important 0 0

A lot 7 5 Slightly important 1 1

A great deal 11 8 Moderately important 12 12

Total 145 100 Very important 31 30

PhD non-ABA coursework on diversity Extremely important 59 57

None at all 15 11 Total 103 100

A little 35 27 Dedication to diversity in coursework (instructors)

A moderate amount 22 17 None at all 13 13

A lot 16 12 A little 33 32

A great deal 19 15 A moderate amount 27 27

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Table 3 (continued) Discussion Comfort level working with individuals from diverse N Percentage backgrounds We found that the majority of respondents (88%) agreed that

training on working with diverse populations is very or ex- A lot 15 15 tremely important. Interestingly, 86% of respondents reported A great deal 13 13 they felt moderately or extremely skilled at working with in- Total 101 100 dividuals from diverse backgrounds, even though the majority

Dedication to diversity in hands-on training (instructors) of participants reported they had little to no training in their None at all 4 5 coursework (82%, behavior analytic; 59% non-behavior ana- A little 20 23 lytic), hands-on training (67%), continuing education (78%), A moderate amount 27 31 or employer training (71%) on working with individuals from A lot 17 20 diverse backgrounds. A great deal 18 21 Although our survey does not allow us to definitively iden- Total 86 100 tify why respondents selected particular responses, we pro-

Note. ABA = applied behavior analysis; CE = continuing education pose some possibilities as to why respondents might have reported they were moderately to extremely skilled with little to no training. First, although respondents may not have had formal training, perhaps respondents had a lot of experience

or spiritual beliefs. Only approximately 1 in 10 respon- working with individuals from diverse backgrounds. This is dents reported asking clients about their religious or spir- supported by the survey results, because 57% of respondents itual beliefs most times (11%) or every time (11%). The reported that 50% or more of their clients were from diverse majority of respondents reported asking clients about non- backgrounds. However, the idea of becoming skilled at deliv- medical treatments sometimes (26%), every time (23%), or ering culturally competent care simply by working with indi- most times (19%) and about dietary preference every time viduals from diverse backgrounds is concerning. The notion (42%), most times (26%), or sometimes (21%). of being skilled by simply experiencing something with no

Only approximately 1 in 10 respondents (12%) asked formal training is antithetical to applied behavior analysis clients about preferences for nonverbal communication, and is akin to thinking one becomes skilled at discrete-trial such as specific preferred greetings or gestures they find teaching with no formal training or one becomes a skilled offensive, every time. The majority of respondents report- practitioner without any specific training. Perhaps we are in- ed sometimes (28%), rarely (25%), or never (20%) asking correctly labeling our comfort with a process as skill clients about preferences for nonverbal communication. implementing a procedure. This, of course, can be quite dan- Whether respondents asked caregivers why they thought gerous not only for the clients we serve but also for our field’s the client had the disorder/diagnosis was relatively split reputation as a whole. We would not allow a therapist to con- across categories, with the majority selecting sometimes duct discrete-trial teaching without formal training, so why are (25%), which was followed by rarely (22%), most times we not affording the same care to working with people from (21%), every time (18%), and never (14%). The majority diverse backgrounds and receiving training on how to best of respondents never (28%), sometimes (22%), or rarely identify and incorporate cultural variables? (19%) asked about preference for male or female thera- Demographic data on certificants are not publicly available pists (which can vary depending on religious beliefs). (BACB, personal communication, March 15, 2018). However,

When asked whether respondents asked clients if the such data could help identify whether our field is representative treatment goals aligned with the family’s values and be- of the population because it is critical to have practitioners that liefs, only approximately two out of five respondents re- represent the population being served. In addition, a limitation ported they asked every time (39%), whereas approxi- of the current study is that our results should be interpreted with mately two out of three respondents reported asking this caution because only 702 BCBAs completed the survey (ap- most times (31%), sometimes (16%), rarely (8%), or never proximately 3% of all BCBAs). We collected demographic (6%). When asked how often respondents worked with a data on respondents; however, the extent to which our sample translator if English was a second language, the majority represents the population of BCBAs is not clear. One important of respondents reported never (28%) or sometimes (26%), aspect of the validity of survey data is ensuring the data are which was followed by every time (16%), rarely (15%), from a representative sample of the population. Although de- and most times (15%). Finally, most respondents reported mographic data on certificants are not publicly available, Nosik being moderately knowledgeable (47%), slightly and Grow (2015) reported that 82% of BACB certificants are knowledgeable (29%), or very knowledgeable (15%) with female, thus suggesting our sample was at least representative differences in parenting across cultures. with respect to gender. Our respondents were primarily non-

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Hispanic (89%) White (84%) female (83%) U.S. citizens (86%) between the ages of 30 and 39 (49%). In a survey con- ducted by the American Psychological Association, they found that 88% of psychology providers were White and 59% were female (American Psychological Association, 2016). It is not clear why the field of psychology is predominately White and female, but it is clear that we should become better at recruiting people from diverse backgrounds. Behavior-analytic providers should consider assessing the demographics in their service areas to determine whether their staff are representative of the demographics and, if not, identifying ways to recruit staff from diverse backgrounds (Fong, Ficklin, & Lee, 2017).

We did not ask respondents whether they delivered culturally competent care. Instead, we asked how familiar respondents were with the process of delivering culturally competent care and then asked various questions that related to practices of delivering culturally competent care. Approximately two out of three re- spondents (60%) reported that they educate themselves on a cli- ent’s culture every time (28%) or most times (32%) if their client immigrated from another country. Although it is good practice to learn about other countries and cultures, we must be cautious with this practice to avoid developing gross generalizations or stereotypes of a culture and applying them to our clients. There are many subcultures within cultures; therefore, identifying gross generalizations will not help us understand our specific clients and their individualized backgrounds. Instead, we should learn how to gather valuable information about the cultural backgrounds of our individual clients and use a culturally competent approach with all of our clients. Triandis (2006) asserts that all humans are ethnocentric—we assume that what is “nor- mal” in our culture is normal everywhere—to a degree. Triandis (2006) further describes how some behaviors emitted by one culture (e.g., loud talking) may be perceived as offensive to an- other culture, but by understanding these idiosyncrasies of cul- tures, we can alter our behaviors to enhance our relationships with others from different cultures. Triandis (2006) urges us to be empathic and attempt to engage in exercises that put ourselves in the shoes of other cultures to help reduce ethnocentrism; how- ever, there are limited empirical data to support the efficacy of such tactics. Perhaps future research could evaluate methods to reduce ethnocentrism and improve relationships with diverse cli- ents through these methods.

Only 39% of respondents reported they asked whether the treatment goals aligned with the values of the family every time (31% reported most times), and surprisingly, roughly one in three respondents (30%) reported they never, rarely, or sometimes asked whether the treatment goals aligned with fam- ily values. This is surprising considering applied behavior anal- ysis is defined by the selection of socially significant behavior (Baer, Wolf, & Risley, 1968), which should be measured through social validity assessments. In other words, applied behavior analysts should always be asking relevant stake- holders if the behaviors are important, the treatment procedures

are acceptable, and the effects are socially significant (Baer et al., 1968; Wolf, 1978). By conducting social validity assess- ments and asking caregivers about the acceptability of behav- iors, procedures, and effects, we are removing our biases devel- oped through our experience in our culture. For example, a U.S. practitioner following safe sleep guidelines outlined by the American Academy of Pediatrics may think it is important for a child under 1 to be sleeping in his or her own bed (Moon & AAP Task Force on Sudden Infant Death Syndrome, 2016), but a family bed (i.e., the child sleeping in bed with the parents) may be more acceptable to the family based on their cultural background. By asking families whether the treatment is social- ly valid, we will gain valuable information as to whether it is culturally appropriate as well. Creating a more culturally appro- priate intervention might help increase the integrity of imple- mentation by caregivers as well.

Furthermore, we found the results were mixed with respect to behavior analysts incorporating culturally competent prac- tices into their service delivery. The majority of respondents reported they asked clients about dietary preferences and use of nonmedical treatments. However, the majority of respon- dents reported they rarely or never asked clients about their religious beliefs, why the client had his or her diagnosis (which may help the practitioner determine the client’s will- ingness for implementation of applied behavior analysis), and the client’s preferred gender of therapist (which may vary for some religions), and the majority rarely or never used trans- lation services for clients whose second language was English. However, our question regarding translation did not ask how often the practitioners asked whether the client wanted inter- pretation or translation services and instead asked how often they interpreted materials. The wording of this question limits our ability to analyze it because perhaps practitioners were not using the services because the clients were declining their use.

If behavior analysts agree that cultural diversity training is important, and the majority have received little to no training nor do they see many behavior-analytic opportunities for such training, how should we proceed? At the molar, or field, level, we suggest the BACB adopt guidelines on working with in- dividuals from diverse backgrounds similar to the guidelines proposed in Fong and Tanaka (2013) and incorporate revi- sions into future versions of the Task List that would require universities to incorporate cultural diversity training in their coursework requirements. Graduate programs should ensure that education and training on working with individuals from diverse backgrounds is weaved thoughtfully through the cur- riculum. Coursework on culturally responsive practices could include topics such as identifying one’s own culture and how it may impact practice, content on the cultural biases implicit in applied behavior analysis, and practicum experiences on how to conduct culturally responsive functional behavioral assessments and home assessments. Conference planners should identify experts in cultural diversity training and invite

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Table 4 Culturally Competent Practices Table 4 (continued)

Familiarity of culturally competent care N Percentage Familiarity of culturally competent care N Percentage

None 29 4 Every time 94 15

Little 77 12 Most times 101 16

Somewhat familiar 203 31 Sometimes 145 22

Moderately 264 40 Rarely 122 19

Extensively 87 13 Never 185 28

Total 660 100 Total 647 100

How often you educate yourself on immigrants’ culture How often you ask if treatment goals align with values

Every time 183 28 Every time 249 39

Most times 208 32 Most times 203 31

Sometimes 185 28 Sometimes 100 16

Rarely 61 9 Rarely 54 8

Never 21 3 Never 41 6

Total 658 100 Total 647 100

How often you ask clients about spiritual beliefs Translator use when English is the second language

Every time 75 11 Every time 102 16

Most times 76 11 Most times 94 15

Sometimes 136 21 Sometimes 166 26

Rarely 163 25 Rarely 99 15

Never 209 32 Never 182 28

Total 659 100 Total 643 100

How often you ask clients about nonmedical treatments Knowledge of parenting across cultures

Every time 149 23 Extremely knowledgeable 21 3

Most times 128 19 Very knowledgeable 92 15

Sometimes 175 26 Moderately knowledgeable 300 47

Rarely 124 19 Slightly knowledgeable 188 29

Never 83 13 Not knowledgeable at all 39 6

Total 659 100 Total 640 100

How often you ask clients about dietary preference

Every time 273 42 them to speak in prominent places at conferences (e.g., key-

Most times 174 26 note addresses) and offer workshops on becoming culturally Sometimes 140 21 competent behavior analysts. Employers should hire diverse Rarely 47 7 clinicians similar to the populations they serve, provide em- Never 26 4 ployees with trainings on cultural diversity, modify paperwork Total 660 100 to be more inclusive of diverse family structures (e.g., using

How often you ask clients about nonverbal communication preferences the term caregiver as opposed to mother and father), and offer Every time 77 12 professional translation and interpretive services. Most times 97 15 At the molecular, or individual, level, behavior analysts can Sometimes 180 28 seek out education on this topic through continuing education Rarely 162 25 opportunities or self-education via the research literature. The Never 132 20 delivery of culturally competent care is a process. The first step Total 648 100 to delivering culturally competent care is self-awareness and

How often you ask caregivers why the client has the disorder/disability identifying how one’s own culture impacts one’s behavior. Every time 116 18 Members of a dominant culture (e.g., White, Anglo-Saxon, in Most times 138 21 the United States) may not see themselves as having a culture at Sometimes 160 25 all and instead think being culturally diverse means nondominant Rarely 141 22 or minority. Therefore, those practicing applied behavior analysis Never 93 14 in the United States who come from a White, Anglo-Saxon Total 648 100 cultural bias may not see that they are lacking information or

How often you ask about preference for male or female therapists knowledge of other cultures because of this cultural “blindness.”

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To be culturally competent, we must recognize our own culture and see other cultures as equally valid to our own. Fong, Catagnus, Brodhead, Quigley, and Field (2016) provide strate- gies for behavior analysts to become more culturally aware. The authors discuss methods to engage in self-assessment to identify one’s own culture and the impact one’s cultural background has on one’s practice of behavior analysis. Once we begin to see how our own culture impacts our behavior, we can better identify cultural variables that affect others.

However, it is imperative that we do not cease our journey to cultural competence after becoming aware. Kodjo (2009) states the second step of culturally competent care is to accept cultural differences and foster a value for diversity. We should provide culturally competent care to all of our clients, not just the ones that may appear different from us, because many cultural variables are not easily visible (e.g., religion, education, socioeconomic status, sexual orientation). We should be incorporating social validity measures with all of our clients and caregivers and incorporating their feedback (i.e., valuing diversity). We should be reminding ourselves that our treatment selections must be based on data and caregiver input (BACB, 2017a, guideline2.09) andnot our values of whether a treatment looks “good”or “bad.”Many treatments in the medical field do not look “good” and often have side effects (e.g., chemotherapy,someformsofphysical therapy,whichcanbe painful), but the treatments are used because they work and the patient has chosen that treatment option. The same applies to be- havioranalysis.Inotherwords, ifyouavoidaparticularevidenced- based procedure (e.g., extinction) because you do not like the procedure or the potential side effects it produces, it is akin to your doctorwithholdingaveryeffective treatment fromyoubecausehe or she does not like the way it looks. Instead, let us empower our clientsbygiving thema fewchoicesof empirically validated treat- ments with full disclosure of side effects and let them decide what “looks”bestfor their family, thesamewayyouareallowedtomake that decision in your doctor’s office. Some families may want the faster treatment that has potential side effects, whereas another family may opt for a gentler approach that takes longer to see effects but minimizes potential side effects. By giving them these choices, we are becoming more sensitive to cultural variables, which may enhance treatment adherence.

Third, we should evaluate the dynamics of difference that may present themselves given the power that is given to those who deliver medical treatment. Fourth, we should assess our cultural knowledge to better understand our limits and seek out assistance when we are working with a population that we are less familiar with so we can determine core principles for a particular culture. Last, Kodjo (2009) recommends fostering the ability to adapt to the diverse needs of our clients and assessing whether we are open to different solutions for the same problem (i.e., providing different treatment options), and perhaps peer review could be helpful in this regard.

Incorporating cultural variables into the delivery of behavior- analytic services is essential, but in order to do so, we must

identify a method to capture these variables. One method is through conducting cultural assessments that involve asking cli- ents various questions related to their family, background, and beliefs (Tanaka-Matsumi et al., 1996). Behavior analysts are experts at assessment and we should be employing this expertise as we learn about our clients’ culture and background to ensure we can mitigate barriers to the delivery of effective treatment. As many assessment tools do not specifically ask about potentially important cultural variables including religion, family structure and hierarchy, important family events or celebrations, and pre- ferred modes and style of communication, behavior analysts will need to modify existing assessments to include these questions. Open-ended indirect assessments can be an excellent way to gather information about a client’s individual background to help the practitioner identify potential barriers and prevent issues. In a way, this type of assessment can be considered analogous to many elements of a functional behavioral assessment. The behavior analyst is attempting to identify target behaviors of the family that facilitate or hinder clinical success, the antecedent conditions under which the behaviors occur, and the reinforcers maintaining these behaviors. Carrillo et al. (1999) provide a list of questions to assist clinicians in gathering infor- mation on cultural variables. Some questions may need to be adapted for behavior-analytic services, and it is important to keep in mind that more research is needed to empirically identify best practices for working with individuals from varying cultures and whether gathering information described in Carrillo et al. (1999) will lead to better outcomes.

In summary, we strongly encourage the behavior-analytic community to take cultural variables into consideration when delivering behavior-analytic services. We also encourage re- searchers to experimentally evaluate the role of culture in behav- ior and best practices for delivering culturally competent behavior-analytic services. Training on working with individuals from diverse backgrounds is critically needed from our degree programs, behavior-analytic employers, and continuing educa- tion providers.

Acknowledgements We thank the Behavior Analyst Certification Board (BACB) for assistance with dispersing our survey to certificants. The opin- ions expressed in this article are those of the authors and not the BACB.

Compliance with Ethical Standards

Conflict of Interest The authors do not have a conflict of interest.

Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institu- tional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

This article does not contain any studies with animals performed by any of the authors.

Informed Consent Informed consent was obtained from all individual participants included in the study.

567 Behav Analysis Practice (2019) 12:557–575

Appendix

Appendix

1. Are you a Board Certified Behavior Analyst (BCBA)? Yes No

2. Which proportion of your clients have diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

Less than 10% 10% to 19% 20% to 29% 30% to 39% 40% to 49% 50% to 59% 60% to 69% 70% to 79% 80% to 89% Greater than 90%

3. How comfortable do you feel working with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

Very uncomfortable Uncomfortable Fairly comfortable Moderately comfortable Very comfortable

4. How skilled do you feel working with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

Very uncomfortable Uncomfortable Fairly comfortable Moderately comfortable Very comfortable

5. How important is it to receive training and education on working with individuals with diverse backgrounds?

Not important Somewhat important Neutral Moderately important Very important

568 Behav Analysis Practice (2019) 12:557–575

6. During your master’s degree education, how much material in your behavior-analytic coursework was dedicated to teaching you how to work with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive

7. During your master’s degree education, how much material in your non-behavior- analytic coursework was dedicated to teaching you how to work with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive

8. During your doctoral degree education, how much material in your behavior-analytic coursework was dedicated to teaching you how to work with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive Not applicable (I do not have a PhD.)

9. During your doctoral degree education, how much material in your non-behavior- analytic coursework was dedicated to teaching you how to work with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive Not applicable (I do not have a PhD.)

10. During your master’s degree education, how much hands-on training (e.g., fieldwork, practicum) was dedicated to teaching you how to work with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive

569 Behav Analysis Practice (2019) 12:557–575

11. During your doctoral degree education, how much hands-on training (e.g., fieldwork, practicum) was dedicated to teaching you how to work with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive Not applicable (I do not have a PhD.)

12. Since becoming certified, how much continuing education have you received teaching you how to work with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive

13. Since becoming certified, how many continuing education (CE) opportunities have you seen offered at behavior-analytic conferences or online teaching you how to work with people with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive

14. How much training does your employer provide you on working with individuals with diverse backgrounds (e.g., different cultures, races, ethnicities, nationalities, religions)?

None Little Some Moderate Extensive

15. How familiar are you with the process of delivering culturally competent care? Not at all Little Some Moderately Extensively

570 Behav Analysis Practice (2019) 12:557–575

16. When working with clients who have immigrated from another country, how often do you educate yourself on their countries’ customs, values, beliefs, and behaviors?

Every time Most times Sometimes Rarely Never

17. How often do you ask your clients about their spiritual beliefs? Every time Most times Sometimes Rarely Never

18. How often do you ask your clients about their use of natural (nonmedical) treatments? Every time Most times Sometimes Rarely Never

19. How often do you ask your clients about their dietary preferences? Every time Most times Sometimes Rarely Never

20. How often do you ask your clients about gestures or nonverbal communication that is important (e.g., specific greetings) to them or offensive to them?

Every time Most times Sometimes Rarely Never

21. How often do you ask the caregivers or clients about their beliefs of the client’s disorder or diagnosis?

Never Barely Occasionally Most of the time Every time

571 Behav Analysis Practice (2019) 12:557–575

22. How often do you ask the caregivers or clients their preferences for male versus female therapists or BCBAs?

Never Barely Occasionally Most of the time Every time

23. How often do you ask whether the treatment goals and procedures align with the families’ values and beliefs?

Never Barely Occasionally Most of the time Every time

24. How often do you work with a translator if English is a second language? Every time Most times Sometimes Rarely Never

25. How knowledgeable are you with differences in parenting across cultures? Very knowledgeable Moderately knowledgeable Somewhat knowledgeable Not very knowledgeable No knowledge

26. How often do you reflect on your own culture and how that may impact your assessment and treatment process?

Not at all Little Some Moderately Extensively

27. When working with families or individuals who have immigrated to your country, how often do you educate them on local laws regarding definitions of abuse and neglect?

Never Barely Occasionally Most of the time Every time

Other: -------

572 Behav Analysis Practice (2019) 12:557–575

28. What is your primary role as a BCBA? Practitioner (direct services) Supervisor Administrator Lecturer/instructor Professor/researcher Other:

29. What population do you primarily work with? Autism spectrum disorder Intellectual disability Special education Emotional or behavioral disorders Mental health General education Brain injury Typically developing Gerontology Employees Child welfare Other:

30. What is your primary work setting? Public school Private school Client’s home Center or clinic College or university Residential facility Hospital Community

31. Which field is your master’s degree in? Applied behavior analysis Behavior analysis Psychology Education Other:

32. Which field is your PhD in? I do not have a PhD. Applied behavior analysis Behavior analysis Psychology Education Other:

573 Behav Analysis Practice (2019) 12:557–575

Other:

33. Select your age. Under 30 years old 30–39 40–49 50–59 60–69 70–79 Greater than 80

34. Select your gender. Female Male Nonbinary/third gender Prefer to self-describe: Prefer not to say

35. Select your race (select all that apply). White Black/African American Asian Native Hawaiian/other Pacific Islander American Indian/Alaskan Native Prefer to self-describe:

36. Select your ethnicity: Hispanic, Latino, or Spanish origin Non-Hispanic, Latino, or Spanish origin

37. There are BCBAs all over the world. What is your current nationality? U.S. citizen Dual citizen (please specify): Other (please specify):

For instructors who teach in BACB-approved course sequences:

38. How important is it to teach students during their graduate studies how to work with individuals with diverse backgrounds?

Not important Somewhat important Neutral Moderately important Very important

574 Behav Analysis Practice (2019) 12:557–575

39. How much material do you dedicate to teaching your students how to work with people with diverse backgrounds during behavior-analytic coursework?

None Little Some Moderate Extensive

40. How much material do you dedicate to training your students how to work with people with diverse backgrounds during behavior-analytic training experiences (e.g., fieldwork, practicum)?

None Little Some Moderate Extensive

Publisher’s Note Springer Nature remains neutral with regard to jurisdic- tional claims in published maps and institutional affiliations.

References

American Psychological Association. (2008). Report of the task force on the implementation of the multicultural guidelines. Washington, DC: Author Retrieved from http://www.apa.org/pi/.

American Psychological Association. (2016). 2015 survey of psychology health service providers. Washington, DC: Author.

American Speech-Language-Hearing Association. (2017). Issues in ethics: Cultural and linguistic competence. Retrieved from https:// www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimen- sions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91. https://doi.org/10.1901/jaba.1987.20-313.

Bailey, J., & Burch, M. (2016). Ethics for behavior analysts (3rd ed.). New York, NY: Routledge.

Behavior Analyst Certification Board. (2017a, July 6). Professional and ethical compliance code for behavior analysts. (Originally pub- lished in 2014). Retrieved from https://www.bacb.com/wp-content/ uploads/170706_compliance_code_english.pdf

Behavior Analyst Certification Board. (2017b). BCBA/BCaBA task list (5th ed.). Littleton, CO: Author.

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Owusu Ananeh- Firempong, I. I. (2016). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293–302. https://doi.org/ 10.1016/S0033-3549(04)50253-4.

Britton, C. V. (2004). Ensuring culturally effective pediatric care: Implications for education and health policy. Pediatrics, 114(6), 1677–1685. https://doi.org/10.1542/peds.2004-209.

Brodhead, M. T., Durán, L., & Bloom, S. E. (2014). Cultural and linguis- tic diversity in recent verbal behavior research on individuals with disabilities: A review and implications for research and practice. The Analysis of Verbal Behavior, 30(1), 75–86. https://doi.org/10.1007/ s40616-014-0009-8.

Carrillo, J. E., Green, A. R., & Betancourt, J. R. (1999). Cross-cultural primary care: A patient-based approach. Annals of Internal Medicine, 130(10), 829–834. https://doi.org/10.7326/0003-4819- 130-10-199905180-00017.

Colby, S. L., & Ortman, J. M. (2014). Projections of the size and compo- sition of the U.S. population: 2014 to 2060 (current population reports no. P25-1143). Washington, DC: U.S. Census Bureau.

Cross, T. L. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are se- verely emotionally disturbed (Vol. 1). Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center.

Flores, G., & Tomany-Korman, S. C. (2008). Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children. Pediatrics, 121(2), e286–e298. https://doi.org/10. 1542/peds.2007-1243.

Fong, E. H., Catagnus, R. M., Brodhead, M. T., Quigley, T., & Field, S. (2016). Developing the cultural awareness skills of behavior ana- lysts. Behavior Analysis in Practice, 9, 84–94. https://doi.org/10. 1007/s40617-016-0111-6.

Fong, E. H., Ficklin, S., & Lee, Y. H. (2017). Increasing cultural under- standing and diversity in applied behavior analysis. Behavior Analysis: Research and Practice, 17(2), 103–113. https://doi.org/ 10.1037/bar0000076.

Fong, E. H., & Tanaka, S. (2013). Multicultural alliance of behavior analysis standards for cultural competence in behavior analysis. International Journal of Behavior Consultation and Therapy, 8, 17–19. https://doi.org/10.1037/h0100970.

Glenn, S. S. (2004). Individual behavior, culture, and social change. The Behavior Analyst, 27, 133–151. https://doi.org/10.1007/BF03393175.

Hoop, J. G., DiPasquale, T., Hernandez, J. M., & Roberts, L. W. (2008). Ethics and culture in mental health care. Ethics & Behavior, 18(4), 353–372. https://doi.org/10.1080/10508420701713048.

Kelly, A., & Tincani, M. (2013). Collaborative training and practice among applied behavior analysts who support individuals with au- tism spectrum disorder. Education and Training in Autism and Developmental Disabilities, 48, 120–131.

Kodjo, C. (2009). Cultural competence in clinician communication. Pediatrics in Review/American Academy of Pediatrics, 30(2), 57. https://doi.org/10.1542/pir.30-2-57.

575 Behav Analysis Practice (2019) 12:557–575

Kowner, R. (2002). Japanese communication in intercultural encounters: The barrier of status-related behavior. International Journal of Intercultural Relations, 26(4), 339–361. https://doi.org/10.1016/ S0147-1767(02)00011-1.

Lang, R., Rispoli, M., Sigafoos, J., Lancioni, G., Andrews, A., & Ortega, L. (2011). Effects of language of instruction on response accuracy and challenging behavior in a child with autism. Journal of Behavioral Education, 20(4), 252–259. https://doi.org/10.1007/ s10864-011-9130-0.

Lo, H. T., & Fung, K. P. (2003). Culturally competent psychotherapy. The Canadian Journal of Psychiatry, 48(3), 161–170. https://doi.org/10. 1177/070674370304800304.

Moon, R. Y., & AAP Task Force on Sudden Infant Death Syndrome. (2016). SIDS and other sleep-related infant deaths: Evidence base for 2016 updated recommendations for a safe infant sleeping envi- ronment. Pediatrics, 138(5), e20162940. https://doi.org/10.1542/ peds.2016-2940.

Morris, M. W., Williams, K. Y., Leung, K., Larrick, R., Mendoza, M. T., Bhatnagar, D., et al. (1998). Conflict management style: Accounting for cross-national differences. Journal of International Business Studies, 29(4), 729–747. https://doi.org/10.1057/palgrave.jibs.8490050.

Nosik, M. R., & Grow, L. L. (2015). Prominent women in behavior analysis: An introduction. The Behavior Analyst, 38(2), 225–227. https://doi.org/10.1007/s40614-015-0032-7.

Parette, P., & Huer, M. B. (2002). Working with Asian American families whose children have augmentative and alternative communication needs. Journal of Special Education Technology, 17(4), 5–13. https://doi.org/10.1177/016264340201700401.

Rispoli, M., O’Reilly, M., Lang, R., Sigafoos, J., Mulloy, A., Aguilar, J., & Singer, G. (2011). Effects of language of implementation on func- tional analysis outcomes. Journal of Behavioral Education, 20(4), 224–232. https://doi.org/10.1007/s10864-011-9128-7.

Simon, R. I. (1992). Treatment boundary violations: Clinical, ethical, and legal considerations. Journal of the American Academy of Psychiatry and the Law Online, 20(3), 269–288.

Skinner, B. F. (1971). Beyond freedom and dignity. New York, NY: Knopf.

Tanaka-Matsumi, J., Seiden, D. Y., & Lam, K. N. (1996). The culturally informed functional assessment (CIFA) interview: A strategy for cross-cultural behavioral practice. Cognitive and Behavioral Practice, 3(2), 215–233. https://doi.org/10.1016/S1077-7229(96) 80015-0.

Triandis, H. C. (2006). Cultural intelligence in organizations. Group & Organization Management, 31(1), 20–26. https://doi.org/10.1177/ 1059601105275253.

Vandenberghe, L. (2008). Culture-sensitive functional analytic psycho- therapy. The Behavior Analyst, 31(1), 67–79. https://doi.org/10. 1007/BF03392162.

Witts, B. N., Brodhead, M. T., Adlington, L. C., & Barron, D. K. (2018). Behavior analysts accept gifts during practice: So now what? Behavior Analysis: Research and Practice. Advance online publica- tion. https://doi.org/10.1037/bar0000117.

Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11(2), 203–214. https://doi.org/10. 1901/jaba.1978.11-203.