Enhancing Mother-Child Ties and Psychosocial Wellness Through Arts: A Mixed Methods Study on Dyadic Expressive Arts-based Intervention for Children With Intellectual Disability and Their Mothers
Phase: NA
Conditions: Intellectual Disability, Mother-Child Relations
Sponsor: The University of Hong Kong

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Study Protocol and Statistical Analysis Plan 
 
 
Unique Protocol ID: EA200329 
 
Brief Title: Enhancing Mother-Child Ties and Psychosocial Wellness Through Arts Among Children 
With Intellectual Disability and Their Mothers 
 
Official Title: Enhancing Mother-Child Ties and Psychosocial Wellness Through Arts: A Mixed 
Methods Study on Dyadic Expressive Arts-based Intervention for Children With Intellectual 
Disability and Their Mothers 
 
Document Creation Date: April 25, 2024 
 
Document version: 5 
 
 

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Enhancing Mother-Child Ties and Psychosocial Wellness through Arts: A Mixed 
Methods Study on Dyadic Expressive arts-based Intervention Group for Children with 
Intellectual Disability and their Mothers 
 
Background: Caregiving mothers of children with intellectual disability (ID) are vulnerable 
to caregiver stress and burnout. Children with ID may have difficulty in expressing emotions, 
thus imposes additional challenges for the parents to understand and interact with them. 
Existing intervention programs for families having children with ID focus on problem- and 
emotion-focused measures, while strategies focusing on improving parent-child relationships, 
mother-child communication and wellness of the dyads are limited. Expressive arts-based 
intervention (EXAT) can bypass verbal expression and cognition during interaction, and is 
also an engaging, enjoyable, and safe process of empowerment. Although evidence has 
supported the use of arts-based interventions for children with disabilities and for parents 
alone, there is a lack of evidence on multimodal dyadic EXAT on the mother-child 
interaction, their relationship and wellness. 
Objectives: The present study aims to investigate the effectiveness of the dyadic EXAT 
group on psychosocial outcomes of children with ID and their caregiving mother. Primary 
outcomes include parent-child relationship, parenting stress, and caregiver burnout; 
secondary outcomes include mother’s affect and quality of life; child’s mood, emotional 
expression, behavioral and emotional problems.  
Method: The present study adopts a mixed-methods design with quantitative, qualitative, and 
arts-based assessment methods. 154 Chinese parent-child dyads (77 dyads in each arm), 
composing of a child (6-12 years) with mild to moderate ID, and the caregiving mother, will 
be randomized into (i) a dyadic EXAT group or (ii) treatment-as-usual, waitlist control group. 
The dyads will be assessed on a questionnaire packet at baseline (T0), post-intervention (T1), 
3-month post-intervention (T2), and 6-month post-intervention (T3). A random subsample of 
mothers (N=30) will be invited to attend in-depth two in-depth interviews at T1 and T3 for 
understanding the experiences, perceived changes, and factors that are attributable to how the 
intervention achieves its intended goals. Data collected will be triangulated to provide an 
integrative evaluation to the effectiveness of the intervention. 
Significance:  This is a pioneer study exploring the benefits of dyadic EXAT on mother-child 
relationship of children with ID, and their psychosocial wellness. This rigorous scientific 
inquiry on the effectiveness of dyadic EXAT in this population can provide empirical support 
to EXAT as an evidence-based, relationship-focused intervention to help these families cope. 
Results of the study could establish EXAT as an evidence-based practice for these families 
and the potential to apply to other populations with children having developmental disorders, 
disabilities, or special education needs.  
Keywords: Mother-child relationship, Psychosocial Well-being, Expressive Arts Therapy, 
Intellectual disability, Randomized controlled trial 

Project Objectives (max. 800 words) 
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Project Objectives 
The primary objective of the present study is to investigate the effectiveness of a 
dyadic Expressive arts-based intervention with reference to a waitlist control group on 
the caregiving mother on the following domains: 
(i) 
Parenting stress; 
(ii) 
Caregiver burnout, and; 
(iii) Parent-child relationship; 
 
The secondary objective of the proposed study also aims to investigate the 
effectiveness of the dyadic Expressive arts-based intervention on other psychosocial 
wellness of the caregiving mothers and children: 
(iv) Mother’s positive and negative affect 
(v) 
Children’s mood (as indicated by a visual analogue); 
(vi) Emotional expressions (as indicated by arts-based assessment); 
(vii)  Behavioral and emotional problems (as perceived by the teachers or social 
workers); 
(viii) Mother’s quality of life;  
(ix) The participating parent’s experiences in the intervention program (through 
qualitative inquiry), and; 
(x) 
The factors that may contribute to or affect the outcomes of the EXAT-
based group intervention 
 
 
 

 
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Pathways to Impact Statement 
The short-term potential beneficiaries 
1. Mothers of children with ID. Mother caregivers of children with ID will have the 
chance to engage in an integrative, engaging, and enjoyable expressive-based 
caregiver support program that could improve caregiver stress, burnout as well as 
cultivate positive affectivity. They can also develop alternative ways to 
understand, communicate, and interact with their children, which may have long-
term benefits also. 
2. Children with ID. Children with ID will have the chance to participate in the 
dyadic EXAT, in which they can express themselves and communicate with their 
caregivers in a safe and enjoyable way through verbal and non-verbal channels.  
This may foster better psychosocial well-being, creativity, and relationship with 
their mother.  
3. Mother-child dyads. Through engaging in art creation and appreciation, mothers 
will acquire a different perspective of their role as a caregiver of children with ID. 
During the collaborative and creative art-making process, mothers will have the 
opportunity to identify non-verbal communication cues and potential in their 
children despite intellectual impairments; these relational changes might help 
mothers view the caregiving experience in new lights, and instill hope and 
enhance their resilience. This would, in turn, facilitate adaptation to the caregiving 
demands in both the short and long runs. 
4. The caregiver community. Improvements in holistic wellness of the caregivers 
would reduce the frequency of mental health and medical service utilization. This 
would save public health costs and relieve the heavy burden on existing healthcare 
services for families. 
The medium-to long- term potential beneficiaries 
5. Expressive arts-based intervention. Results of the proposed study will contribute 
to the development of the use of expressive arts-based intervention as a care 
support modality for caregivers of children with ID or other children who have 
difficulties in cognition, communication and expression. This would bridge the 
existing research and service gaps in caregiver support services locally and 
globally. The study findings will inform us the underlying principles/factors that 
modulate the effectiveness of the program, channel existing knowledge gaps in 
arts-based intervention, lay the foundation for integrating expressive arts-based 
services into existing social service system, and reinstate the role expressive arts 
play in evidence-based, caregiver support services within the community. 
6. Researchers in psychology, social work, and related disciplines. The study 
findings will broaden our understanding of how arts-based interventions establish 
the resilience and flourishing of caregivers of children with ID, as well as help 
foster the positive relationship with their children. Such knowledge advancement 
will open a new arena for conceptualizing and developing expressive arts-based 
interventions for caregivers and other populations that might potentially benefit 
from arts-based modalities. 
7. Mental health policymakers. Findings from this study could indicate the 
development of appropriate support service for caregivers having children with ID 
or disabilities, as well as mental health services and care policies in the long run.   
8. Other populations with developmental disabilities. Findings from this study could 
be generalized to other clinical populations of parents and their children with 

 
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developmental disorders or disabilities, or with cognitive, communicative and 
expressive problems.  
 
Plan to increase the likelihood of achieving the identified benefits and reaching the 
identified beneficiaries 
Collaborative efforts of a multidisciplinary expert team. Members of the 
multidisciplinary research team are experts in the practices and research in the areas 
of expressive arts-based intervention, intellectual disabilities, family-based 
intervention, and psychosocial interventions for chronic illness and community 
wellness. They showcase an established track record of research outcomes in terms of 
publications and local and overseas conference presentations in the field of social 
work, holistic healthcare, psychology, pediatric psychiatry, and expressive arts 
therapy. To ensure the identified impacts could be achieved and delivered to the said 
beneficiaries, the team will work collaboratively on execution, coordination, and 
implementation of the proposed project, ensure treatment fidelity, and accuracy in 
data collection and data analysis. The team will ensure this project achieving its 
expected impacts by collaborating with the network of long-time collaborators in the 
community serving people with ID and their family members. Hong Chi Association, 
one of the local, dedicated non-government organizations which serves over 7,000 
people of all ages and all grades of ID, has already offered its support to this project. 
 
Protocolized treatment with fidelity and sensitivity. The components of the proposed 
EXAT program have been developed and applied in various clinical populations, 
including adults and children with ID. The acceptability, efficacy, and feasibility of 
the program components have been tested by the research team [1-3]. The project 
team has carefully reviewed their experiences in the field and fine-tuned the content 
so that the program could be delivered in a dyadic format to serve both the children 
and mothers simultaneously and suit for local population [3]. The treatment protocol 
has been manualized to ensure fidelity. Extra care will be taken into consideration to 
ensure the safety and health condition of group participation. The dyadic group 
sessions will be conducted in face-to-face format due to the need for interactions. In 
case of pandemic within the community, larger venue will ensure adequate spacing 
and social distancing between the participating dyads as precautionary measures. We 
also plan to develop online format in the future based on this study; yet the dyadic 
intervention involves interactions among the mother, the child, and the therapist, it 
may need more time to develop and validate the virtual approach. 
 
Dissemination of knowledge. This proposal will generate high quality research 
findings which will be disseminated in international conferences and academic 
publications in international peer review journals. Other forms of knowledge 
exchange initiatives will include public talks, seminars, and professional workshops to 
disseminate the research findings and practices insights with community collaborators 
and other stakeholders in the field. These events will be carefully integrated into the 
program plans of our collaborators so that the healthcare professionals, service users, 
and public could access these findings and their practical implications, and generate 
public momentum for potential policy changes in supporting caregivers of children 
with ID and other disabilities. The project will involve trainees of Expressive arts-
based intervention and other healthcare professionals. This may help them develop 
their practical skills for serving this population or other populations in the community.  

 
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Background of Research 
Intellectual disability (ID) is a developmental disorder characterized by significant deficits in 
both intellectual and adaptive behaviors which result in restrictions in learning, 
communication, self-care, social skills, and adaptive skills [4]. It typically manifests in the 
developmental stage of childhood or adolescence. Intellectual disability is universally 
classified from mild, moderate, severe to profound range [5], based on standardized IQ 
assessments. In Hong Kong, the enrollment statistics for students with ID in 2019/2020 
indicate a prevalence rate of 0.87% (approximately 7, 700 individuals) of the school age 
population [6]. Since children with ID may need assistance in almost all aspects of life, 
caregiving for children with ID can be overwhelming and taxing, and may cause disruptions to 
the social, occupational, and physical functioning of the caregivers’ family [4], leading to 
caregiver stress and burden [7], and worsened overall quality of life [8].  
Psychosocial Needs of Family with Children having Intellectual Disability 
Caregiving for a child with intellectual disability (ID) is a lifelong commitment that affects 
members of the family. A recent tragedy of a caregiving mother who killed her own child 
having ID in Hong Kong raised the alarm of mental health issues of and support for family 
caregivers, in particular the mothers, who are more vulnerable to the negative impacts of 
caregiving than the fathers [9]. Caregiving stress/ burden is the negative perception of the 
caregiving experience; it is conceptualized as how an individual perceives and appraises events 
in relation to personal or other accessible resources [10]. Caregiving burnout is a 
multidimensional construct encompassing physical and psychosocial exhaustions experienced 
by the caregivers, which is a result of prolonged exposure to caregiving stress [11]. The 
primary source of caregiving stress of children with ID comes from the disrupted affective 
relationships among family members. Children with ID tend to have difficulty in expressing 
their thoughts and feelings verbally; thus increasing their likelihood to display emotions in 
form of maladaptive behaviors that aggravated social relationships and other psychosocial 
problems  [1, 12]. Proper management and regulation of the relationships are thus critical for 
mitigating against caregiving stress and caregiver burnout [13].  
Psychosocial interventions have been deployed to help families with child having ID, 
including parents’ skills training, cognitive behavioural therapy, behavioural management 
programs for children with ID, or peer support services such as volunteering [13, 14]. While 
these programs offer supportive care to the caregivers, they are mostly problem- and 
emotional-focused [15], and were found to be inadequate in protecting against caregiver 
burnout resulted from interpersonal conflicts that are rooted in disrupted affective relationships 
among family members with high caregiving demands [16]. Contrarily, interventions that 
emphasize relationship-focused coping might be more culturally relevant in helping 
caregivers build resilience [15]. Relationship-focused coping focuses on behaviors that are 
instrumental in enhancing family relationships; and should also emphasize on the promotion of 
positive interactions of the parent and the child, as well as offering ways other than verbal or 
cognitive approach for promoting mutual understanding and communication within the dyad 
[13]. Furthermore, research also suggested that caregivers’ well-being also has important 
implications to the quality of caregiving and the recipients’ well-being with potential 
reciprocal effects [17]. Thus, there is an imminent need to support caregivers of children with 
ID to preserve both parties’ well-being and prevent the occurrence of reciprocal suffering.  
Why Expressive arts-based intervention (EXAT)? 
Expressive arts-based intervention (EXAT)  integrates psychotherapeutic skills with the use of 
the intrinsic expressive and healing power of arts, and seeks to engage the client holistically 
across the physical, cognitive, emotional, social, aesthetic, and transpersonal domains [18]. 
This approach uses different creative arts modalities (arts, dance/ movement, drama, music, 

 
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and other forms of arts expression) in an integrative way as a vehicle for establishing 
interpersonal connections (verbal or non-verbal), encouraging aesthetic appreciation (non-
judgmental attitude), and cultivating mutual understanding and appreciation [18].  EXAT takes 
a “low-skill high-sensitivity approach”, as such the participants do not have to be proficient in 
any verbal or non-verbal communication skills, or arts ability; they would be facilitated to 
become sensitive to whatever they are experiencing so that they could engage creatively and 
meaningfully in different arts media, and find way of working with the situation that feels “just 
right” to them [18]. The use of different elements from EXAT has attracted much attention in 
community setting due to its safe, engaging, enjoyable process, and its non-pharmacological 
and strength-based orientation [19]. The use of arts also showed benefits in strengthening of 
the relationships within the family by promoting empathy, cultivating sensitivity to each 
other’s needs, modifying the habitual perception of the other family members, and establishing 
a more adaptive stance towards conflicts [20]. Moreover, a study on art facilitation with 
individuals who had developmental disabilities indicated improvements in communication and 
social relationship in the treatment group [12]. Music therapy was also found to benefit the 
parent-child relationship through the improvement of communication, the feeling of closeness 
and understanding [21, 22].   
Theoretical Basis of Dyadic EXAT in Improving Mother-Child Dyads Wellbeing 
Intervention strategies that help to facilitate and maintain relationship for children with ID and 
their caregiving mother, would help buffer against caregiver stress, prevent caregiving burden, 
and improve wellness of the caregiving dyads [2, 23].  However, the difficulty of children with 
ID in expressing their thoughts, needs, and emotions to their caregivers may impose additional 
hindrance in maintaining proper relationship. The use of arts can bypass the cognitive and 
verbal limitations [1, 24]. Multimodal EXAT may also help tap into different sensory channels 
for communication, expression, perception and interactions, and satisfy the different 
preferences of expressive channels that individuals or the dyad may have, while offering 
opportunities for them to explore new ways of knowing and interacting with each other [12, 
18]. All these are shown to be important in building relationship, and strengthening attachment 
between the dyad [21, 23, 24]. In addition, given the reciprocal nature of interaction between 
the caregiver and the recipient, intervention that focuses on the caregiving dyads could be 
particularly beneficial. Evidence suggested that dyadic groups using different arts forms might 
help relieve caregiving stress though the followings: 
Improving Mother-Child Communication. EXAT helps overcoming the barrier of the 
difficulties of children with ID in expressing their emotions and understanding of others’ 
emotions; thus, offering empowering and support to the parents [25], and strengthening the 
mother-child dyadic ties. In addition, communicating and expressing through arts are 
especially appropriate for local population as Chinese custom in which explicit displays of 
affection and emotion are generally considered inappropriate [26]. Evidence has shown the 
potential benefits of a dyadic expressive arts-based intervention on the mother, the child, as 
well as the mother-child relationship [2], and increasing prosocial behaviours of pre-school 
healthy children and positive affect of their caregivers [3].  
Acquiring New Ways of Relating. The dyadic EXAT emphasizes the process of co-creation and 
exploration with arts; which encourages joint looking and shared sensory experiences between 
the mother and child. This will prompt the dyads to try out new strategies to communicate and 
relate to each other [2], facilitate better communication, and help secure their attachment [24]. 
Such exploration will also allow children more room to express or in charge of this new 
dynamic; open new ways for the mothers to understand, appreciate, and interact with their 
children [27]; benefit the relationship; enhance parental sensitivity; and facilitate the 
improvements of caregiving burden and well-being for the dyads [23].  

 
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Soliciting Social Support Within and Between the Families. Dyadic group intervention allows 
social support to synergistically emerge between the family dyads; whereas experiences of one 
family unit could provide the avenue for other families to model alternative communication 
patterns [26, 27]. When the group uses arts to share what they normally cannot verbalize, they 
open up possibilities for unexpected common themes for discussion and exploration [27]. The 
dyadic group format also allows the mother to connect more with the program, display 
attention, kindness, and appreciation of the child, rather than only learn practical skills for their 
children or resolve their own emotional issues [26].  
Although evidence are accumulating on the use of arts-based elements to help families with 
children having disabilities to cope, existing evidence is plagued by: (i) small sample or not 
homogenous sample of children with ID; (ii) not having children in the intervention, (iii) no 
exploration on children’s emotional expression and mood in outcomes; (vi) interventions with 
single art modality; (v) without post-intervention data collection time points. To address the 
above limitations and knowledge gaps, this study may generate rigorous multi-dimensional 
research evidence to support the use of dyadic EXAT which puts equal emphasis on the 
experiences and interaction of the mothers and children with ID. The study will bridge both the 
knowledge gap on the application of dyadic EXAT and service gap in supportive care for 
families with children having ID or other special needs (SEN) locally and internationally. 
Work Done by the Team 
Prof. Rainbow Ho (PI) has rich experience in clinical practice and research in expressive arts-
based intervention, including its cultural adaptation, and psycho-physiological outcomes [28]. 
She also has experiences in conducting mixed methods RCT on clinical populations including 
ID and the caregivers [1, 3, 29], and the use of arts-based assessment [2]. Dr. Phyllis Wong is 
an experienced researcher-practitioner in the field and has done a lot of works on investigating 
the quality of life and self-determination of people with disabilities, as well as in resilience of 
caregivers of people with intellectual disabilities [14, 30]. Dr. Herman Lo is an experienced 
researcher and practitioner in family-based interventions [3,5] , parenting, caregiving, and 
children with special needs and developmental disabilities [29, 31]. Dr. Adrian Wan’s 
research focuses on holistic wellness, mindfulness, expressive arts-based intervention, and 
social work practices in patients and caregiver supports [3, 32]. The team members has 
conducted important groundworks for the proposed project, which included applying EXAT 
for adults with ID, working with parents and children with or without special needs, family-
based interventions, and other projects related to supporting individuals with disadvantages. 
These experiences will ensure proper implementation of the project and its high quality, as 
well as translation of the research findings to practical wisdom locally and internationally.  
Research Plan and Methodology 
Study Hypotheses. The proposed study attempts to explore the following hypotheses: 
1. The Dyadic Expressive arts-based intervention Group is more effective than the treatment-
as-usual, wait-list control in improving parental stress, caregiver burnout, positive and 
negative affect, quality of life and parent-child relationship. 
2. The Dyadic Expressive arts-based intervention Group is more effective than the treatment-
as-usual, wait-list control in improving the behavioral and emotional difficulties, mood 
states, and expression of emotions of young children with ID. 
3. Changes observed/ reported by participants in the dyadic expressive arts-based intervention 
group are sustai6nable at 3-month and 6-month post-intervention follow-up time points. 
Exploratory Questions. The proposed study will also attempt to explore the followings: 
4. To explore the relationships of the psychosocial variables and intervention effectiveness 
(e.g. meditation, moderation and other asosocaitions). 

 
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5. What are the participating mothers’ experiences in the dyadic expressive arts-based 
intervention group? 
6. The potential factors and conditions that may affect how and why the EXAT intervention 
works or does not work for the participating dyads; mothers’ perception, acceptability, and 
real-life application of the non-verbal communication skills that they explored and 
practiced in the intervention.  
Study Design and Methods of Data Collection 
Study Design. This proposed study adopts a RCT with mixed methods design. To address the 
research objectives, data collected will be triangulated and interpreted simultaneously to 
address the research questions. Appendix A depicts the CONSORT flow diagram of the 
present study. Outcome measures will be assessed on four time-points (T0: Pre-intervention at 
baseline; T1: Post-intervention; T2: 3-month post-intervention and; T3: 6-month post-
intervention) to assess the immediate and sustained effects of the Dyadic EXAT Group on 
mother-child relationship and psychosocial wellness. Qualitative interviews will be conducted 
with a random subsample of 30 parents from the expressive arts intervention at T1 and T3 to 
collect fine-grained, information to explore their overall experience of participation in the 
intervention and how the experience has shaped their caregiver experience in terms of stress 
coping and establishing parent-child relationship. Results of the qualitative interviews will be 
used to enhance the interpretation and understanding of the quantitative findings [33]. 
Appendix B summarizes the conceptual framework of the proposed study. 
Participants.  Participants are mother-child dyads composing of a mother caregiver and a child 
who is aged 6 -12 years (primary school student) and fulfils the diagnostic criteria for mild 
grade to moderate grade ID (based on the age-relevant IQ test assessments administered by a 
qualified professional). In the judgment of health/school professional staff, the child is capable 
of responding to assessments and participating in group activities. The dyads are able and 
willing to give consent for participation in the study (guardian’s assent consent will be 
arranged for the participating children, while written consent will obtained from the adult 
mothers). Dyads are excluded if: (i) the dyad is currently participating in any other behavioral 
or pharmacological trial, and/or (ii) either member of the dyads have other contraindications or 
severe comorbidities that may impair their full participation (e.g. severe physical disabilities). 
Recruitment. The recruitment will be facilitated by our collaborative partners in the 
community (including SEN schools, and community-based units that serve families of children 
with ID), as well as referral from medical and mental health professionals working in the field 
of education, paediatric psychiatry, clinical psychology, and social work. The promotion 
materials will be hosted on the website/social media of the Department of Social Work and 
Social Administration and Centre on Behavioural Health of The University of Hong Kong. 
Screening for eligibility will be conducted by the researcher or referral professionals who have 
attended briefing sessions offered by the research team. 
Sample Size: We expected a moderate effect size of 0.5 for the primary outcomes based on a 
local study [57]. Using power analysis software Gpower 3.1, assuming an attrition rate of 20%, 
a total sample size of 154 participants (i.e. 77 each arm) will provide 80% statistical power to 
detect an effect size of 0.5 in the 2-arm RCT with 4 measurement time points at 5% level of 
significance. For the qualitative data collection, a random subsample of 30 participating 
mothers will be invited to join individual, in-depth interviews at post-intervention (T1) and 6-
month follow-up (T2). Based on various guidelines for mixed methods study design, a sample 
of 25 participants would suffice data saturation. If data saturation is not reached, more 
participants will be recruited into the study until no more new findings emerge [34].  
Group Allocation. Eligible family dyads will be randomly assigned into one of the two study 
conditions on a 1:1 basis using a randomization table and a computer-assisted random number 

 
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generator. The allocation list will be produced by an independent researcher and concealed 
from other researchers and participants until assignment. 
(a) The Dyadic Expressive Arts Group Therapy: The 8-session intervention group (weekly 
session, 90 minutes each, with 3-4 dyads in 1 group) delivered will be by a registered 
Expressive Arts Therapist or an expressive arts therapy trainee, or a mental health professional 
trained in expressive arts intervention (under supervision). Each session consists of 5 basic 
processes in EXAT: check-in, warm-up, core art making, sharing, and closure [35]; and 
focuses on a specific theme related to parent-child relationship: communication, relationship, 
expression, empathy, interaction, love, gratitude, and connection. The program has been 
developed and adopted for people with ID and mothers of children having special needs and 
disabilities [1, 2, 36], and has been refined to integrate the cultural-relevant components (e.g. 
Chinese festivals, Chinese arts and music, etc.) and parent-child interaction skills and elements 
[2, 3]. The program has been used by the team in previous studies and community workshops 
[37-40]. Appendix C summarizes the structure of the program. 
(b) The Treatment-as-usual Waitlist Control Group: The control group will continue with 
routine healthcare and social services and will be invited to participate in a similar intervention 
group program upon completion of the 8-month study period. 
Treatment fidelity: Group facilitators participating in the intervention delivery will receive a 
training session covering the details of the protocol and safety precaution. Treatment fidelity 
will be assessed by the PI in the form of on-site or video-reviewing supervisions, preferably 
during the 3rd or 4th session on the condition that written consents are provided by the 
participants. The facilitators will receive off-site supervision provided by the PI. The 
assessment will be conducted using a pre-constructed observation checklist outlining the 
program pedagogy and the expected goals of the sessions.  
Research ethics: Ethical approval will be obtained from the Institutional Review Board and 
Human Research Ethics Committee prior to data collection, and consent will be obtained from 
all recruited participants (the mothers, and children with ID) prior to assessment. The study 
will be registered in the ClinicalTrials.gov under the National Institutes of Health, and the 
HKU Clinical Trials Registry. 
Measurements 
Mother’s psychosocial outcomes and perceived parent-child relationship 
1. Parenting stress. The 36-item Parenting Stress Index (4th Ed, Short-form) (PSI/SF) [41] 
will be used to assess parenting stress of the mothers on 3 domains: (i) parental distress, (ii) 
parent-child dysfunctional interaction, and (iii) difficult child. The index reported an 
internal consistency of .92, and has been adopted in local studies of mothers with children 
having special education needs [42]. Higher scores indicate higher parenting stress. 
2. Caregiver burnout. The 6-item client burnout subscale of the Copenhagen Burnout 
Inventory [43] will be used to measure the mothers’ caregiving burnout. This scale has a 
central focus on fatigue and exhaustion which matches the definition of burnout; and this 
scale has been validated with good reliability in local context and has been used in a study 
on Chinese caregivers of individuals with ID [44]. The subscale used is rated on a 5-point 
Likert format ranging from 0 (“never/ to a very low degree”) to 100 (“always/ to a very 
high degree”), with higher scores indicating higher levels of burnout. 
3. Parent-child relationship. The subscales of parent-child communication (9 items) and 
satisfaction with parenting (10 items) from the Parent-Child Relationship Inventory (PCRI) 
will be used to measure the mother’s perceived attitude towards parent-child relationship 
[45]. The items are rated on a 4-point Likert Scale from (1) strongly agree to (4) strongly 
disagree; and negative items are reversed coded. Higher scores indicate positive perception 
of the specific dimensions of parenting perceived by the caregiving mother. The research 

 
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team will undertake the authorized translation of the subscales.  
4. Positive and negative affect. The 10-item International Positive and Negative Affectivity 
Schedule – Short Form [46] measures positive and negative affectivity of the mothers on a 
5-point Likert format, ranging from 1 (“Never”) to 5 (“Always”). The scale yields positive 
affect and negative affect subscales. Higher scores in each subscale indicate more of that 
affective state for the respondent. 
5. Quality of life. The 28-item WHO Quality of Life Scale, Brief version (WHOQOL-BREF) 
[47] addresses physical, psycholgoical, social, and environmental quality of life. The 
Chinese version has been adopted in a study of caregiver burden of parents with children 
having ID scores denoting better quality of life in a specific domain. 
6. Psychological well-being. The 5-item World Health Organization Five Well-Being Index 
(WHO-5) [48] measures the subjective psychological well-being on a Likert scale, ranging 
from 5 (“All of the time”) to 0 (“At no time”) in the past 2 weeks. Raw score is converted 
to a percentage scale to provide a score of 0 to 100. Higher scores reflect higher subjective 
well-being. 
Children’s psychosocial outcomes 
7. Mood states. The Ottawa Mood Scales are a series of Likert scales desinged to help children 
express how they feel [49]. The scale is composed of 5 items which asesss mood, anger, 
worry, stress and self-regulation. For self-regulation, there are faces depicting the 
corresponding emotional states and a thermometer icon represent the arousal state at the 
bottom. For mood, anger, worry and stress, there is a numerical scale with schematic faces 
showing the corresponding emotions.  The tool has been valdiated to use in a Malaysian 
young adult sample [50]. The research team will undertake the translation of this scale. 
8. Emotional expression. The Face Stimulus Assessment [51] is an arts-based projective 
assessment which is a viable means of extracting psycholgoical information including 
emotional expressions for individuals with communication difficulties, including ID [52]. 
The assessment contains a series of three A4-size stimulus drawing templates: the first is a 
pre-drawn face, the second is a face outline, and the third is a blank sheet of paper. 
Participants will be asked to use the markers provided on the templates individually. The 
FSA will be administered in small groups and assessed through a quantitative and 
qualitative approach following guidelines from the FSA E-Packet and Rating Manual (2nd 
ed.) [51, 53]. The artworks will also be digitally scanned to analyze the pattern of color 
usage [1]. This assessment will be conducted by a trained Expressive Arts Therapist, a 
EXAT Trainee under supervision, or a trained research staff. 
9. Behavioral and emotional problems. The 113-item Child Behavior Checklist (Teachers’ 
Report Form) measures behavioral and emotional behaviors related to child functioning and 
problem behaviors observed by the teachers/professionals [54]. The Chinese version is 
widely adopted in Hong Kong with established local norms [55]. School teachers or social 
workers of the participating children will be invited to fill in the checklist and indicate the 
degree or frequency of the behaviors described in the checklist on a scale of 0 (not true), 1 
(somewhat or sometimes true), or 2 (very true or often true). The checklist yields three 
composite scores on externalizing, internalizing, and total behavioral problems, and eight 
syndromes of withdrawn, somatic complaints, anxious/depressed, thought problems, social 
problems, attention problems, deliquent behaviors, and aggressive beahvior with higher 
scores indicating greater manifestations of the described behavior problems in the area [56].  
Other variables 
10. Demographics: Participant profile including age, gender, education level, income, 
employment status, religiosity, marital status, and family composition will be recorded. 
Clinical information (time since onset/ diagnosis, medical treatment record, psychiatric 

 
7 
history, comorbidity (physical disabilities, hypertension, diabetes mellitus, or other 
cognitive disturbance) and history of rehabilitation service utilization of the parents and 
children will be documented. 
In-depth Interviews: 30 participating mothers will be invited to attend two individual, in-depth 
interveiws at post-intervention (T1) and 6-month follow-up (T3) respectively. The first 
interview focuses on the immediate post-intervention changes percieved by the mothers upon 
program completion, while the second interview focuses on the sustainability of these changes 
at 6-month follow-up and explores additional changes that were observed between the follow-
up windows. The interviews will be conducted by member of the research team (who are 
familiar with mixed-methods study design, in-depth interview), assisted by a research 
assistant, using an interview guide [57]. Appendix D shows the sample interview guide and its 
potential probes. 
Data Analysis: Analyses of the outcomes will be performed according to standard intent-to-
treat principle to address the effects of crossover and dropout. Missing data for the participants 
who drop out of the study at follow-up assessments will be handled using the full information 
maximum likelihood method. This method has been shown to produce unbiased estimates for 
clinical trials with missing data [58].  
1. Effectiveness of Dyadic EXAT group (Hypothesis 1 – 3). Descriptive statistics will be used 
to summarize the socio-demographic characteristics of the participants at all time points. 
Primary analysis of treatment outcomes will be conducted using mixed-effects regression 
models. Mixed-effects models analyze the repeated measurements between groups to 
obtain the time effect, group effect, and group*time effect. The analysis will adopt the 
intention-to-treat principle to account for the missing data. Missing data for participants’ 
dropout will be handled using full information maximum likelihood method [58]. Effect 
size of the intervention will be evaluated using Cohen d [59], with 0.2, 0.5, and 0.8 
denoting cut-off of small, moderate, and large magnitudes. Demographic and clinical 
variables will be controlled in the analysis. All statistical tests will be two tailed and 
statistical significance will be set at 0.05 using Mplus 8.3. 
2. Process and Mechanism of Dyadic EXAT (Exploratory research question 4). Path analysis 
will be performed to examine the mediating role of parent-child relationship and parenting 
stress on the effect of EXAT on psychological distress and caregiver burnout. The path 
model will be built for the predictor variables at baseline (T0) on the dependent variables at 
T3 via the mediators at post-intervention (T1) and 3-month follow-up (T2). Mediation 
effects will be assessed through the significance of the indirect effects from EXAT to 
psychological distress and caregiver burnout via the mediators. Given the likely non-
normal distribution of the product terms of indirect path coefficients, confidence intervals 
of the indirect effects will be estimated using the bootstrapping approach [60].  
3. Individual experiesnce of Dyadic EXAT (Exploratory research question 5-6). Qualitative 
data from the open-ended questionnaire packet will be converted into electronic text file 
for data analysis. The interviews will be audio-taped, and transcriptions will be produced 
by a research staff who have not been involved in the interventions. All data will be input, 
managed, and analysed using NVivo 12.0 or above. Analysis will be performed using 
inductive thematic analysis method. Transcripts will be coded, and themes will be 
identified by a research team member who is experienced in qualitative data analysis. 
Thematic analysis will be adopted to code the data; and the coded units will be put into 
categories and subcategories, and recurrent themes and patterns will be explored. Audit 
trial will be conducted to ensure data credibility. The findings of the arts-based 
assessments and emerging themes will be reviewed for resonance with the quantitative 

 
8 
data, and triangulated to assess the effectiveness of the intervention, and to identify the 
potential pathways for therapeutic group. 
 
 
 

 
9 
Ghantt Chart (Study Period: 3 years) 
 

 
10 
Appendix A: CONSORT diagram for the proposed study 
 
 
Appendix B: Conceptual Framework of the proposed study 
 
 
 

 
11 
Appendix C: Sessions Outline & Structure of an EXAT Dyadic Group Session 
 
 
 
Appendix D:  Interview Guide for Qualitative Interview 

 
 
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