Acceptability of Behavioral Family Therapy among Caregivers in China
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- Yu, J., Roberts, M., Wong, M. et al. J Child Fam Stud (2011) 20: 272. doi:10.1007/s10826-010-9388-1
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In the U.S., helping the noncompliant child and parent child interaction therapy represent behavioral family therapy programs that are empirically supported for treating the conduct problems of 2- to 7-year old children. This study examined how caregivers in China would view behavioral family therapy. Caregivers in Hangzhou, China reported the perceived age of deviance for behavioral family therapy targets (e.g., noncompliance) and rated the acceptability of behavioral treatment components (e.g., timeout). Chinese caregivers agreed with European-American culture on considering noncompliance, aggression, tantrums, and negative talk deviant during the pre-school period. Overall, Chinese caregivers considered all the following nine behavioral family therapy components acceptable: contingent praise, responsive play, ignoring deviant attention seeking, authoritative instruction-giving, warnings, chair timeouts, ignoring tantrums during timeout, room backups for chair timeouts, and immediate timeouts for aggression. However, specific parental reservations were found regarding backup procedures for chair timeouts, particularly room backups. Possible treatment accommodations of behavioral family therapy for Chinese families are discussed.
KeywordsBehavioral family therapyDisruptive child behaviorTreatment acceptabilityCultural accommodationsChina
Conduct problems among youth are significant in China. A survey of 2,468 children ages 2–3 showed 3.2% prevalence rate for externalizing problems (Liu et al. 2003). A recent study of 9,089 children ages 4–6 found that the prevalence for externalizing problems was 9.2% (Li et al. 2009). Additionally, Guan (2006) found an 11% prevalence rate of aggression among Chinese children ages 3–6, specifically, 13% for boys and 7% for girls. All of the above studies used versions of the child behavior checklist (CBCL) that were normed in China (Liu et al. 2003; Xin et al. 1992).
In the U.S., helping the noncompliant child (HNC) (McMahon and Forehand 2003) and parent child interaction therapy (PCIT) (Hembree-Kigin and McNeil 1995) represent behavioral family therapy (BFT) programs that meet the “probably efficacious” standards of Division 12 of the American Psychological Association (Eyberg et al. 2008) for treating the conduct problems of 2- to 7-year old children. Initially targeting European-American families, PCIT has been successfully adapted to Mexican-American (McCabe et al. 2005), African-American (Coard et al. 2004), and Native-American cultures (BigFoot and Funderburk 2006). Adaptations have also been attempted for Puerto Ricans (Matos et al. 2006) and in some other parts of the world including Australia, Hong Kong, the Netherlands, and Norway (McNeil and Hembree-Kigin 2010). In contrast, BFT approaches for treating disruptive child behavior in mainland China are virtually non-existent.
A search of the Chinese literature found only one article briefly describing PCIT (Zhang and Lu 2008). There is also a remarkably limited literature on the professional treatment of Chinese 2–7 year-old children’s behavior problems. Interventions studied by Chinese professionals include sand-play therapy (Long 2008), Adlerian mutual storytelling therapy (Zhao 2007), social skills training (Wang 2006; Wang et al. 2007), sensory integration training, and child-rearing guidance (Yu et al. 2006; Zhao et al. 2007). All Chinese interventions were found to be more effective than no-treatment. Sensory integration training and child-rearing guidance, however, required up to 3 years to complete, compared to the typical 2–3 months for standard HNC/PCIT programs. The effects of storytelling therapy and social skills training were limited by children’s language development. Most importantly, all of these interventions failed to target specific externalizing problems (e.g., noncompliance). Clearly, the Chinese CBCL normative comparison data and treatment literature indicate a need for empirically supported BFT programs like HNC or PCIT to treat disruptive behavior problems in China. The next step would seem to be an empirical trial in China.
However, it is unknown how Chinese caregivers (mothers, fathers, and grandparents) would view BFT. First, do Chinese caregivers agree with BFT treatment goals? Second, how acceptable are BFT intervention components among Chinese caregivers? The current study examined these two questions, both of which are linked to the social validity of a treatment (Wolf 1978). Social validity refers to the subjective value judgment by a society about the social significance of treatment goals (i.e., do Chinese caregivers really want the BFT goals?), the social appropriateness of the treatment procedures (i.e., do Chinese caregivers consider BFT procedures acceptable?), and the social importance of treatment effects (i.e., are Chinese caregivers satisfied with the results?) (Wolf 1978).
Treatment goals relate directly to the presenting problems that lead a client to seek treatment (Foster and Mash 1999). If Chinese caregivers disagree with BFT treatment goals, then they would not seek BFT nor consider BFT relevant. BFT generally targets four typical disruptive behaviors among children ages 2–7 years: noncompliance, aggression, tantrums, and negative talk (Roberts 2008). If Chinese caregivers consider these disruptive behaviors unacceptable in 2- to 7-year-old children, they should be motivated to seek professional assistance. Consistent with this possibility, Chinese culture values group harmony and moderation such that a lack of behavioral and emotional control is considered problematic (Cen et al. 1999; Ho 1986). Confucian teachings emphasize parental training of children to be well mannered and manifest behavioral composure, affective control, and gentle speech (Wu 1996). Child compliance, self-control, and limit setting are among the main parenting beliefs in contemporary Chinese mothers of 2- to 6-year-old children (Li et al. 1997). Chinese parents often begin to discipline child aggression around 2.5 years of age (Ho 1986). Therefore, it is hypothesized that Chinese caregivers would agree with the BFT goals to treat the basic four disruptive behaviors of 2- to 7-year-old children.
Treatment acceptability refers to the extent to which potential consumers of a treatment perceive each procedure as appropriate, palatable, and effective (Kazdin 1981). Acceptable treatments are related to increased cooperation, compliance, therapeutic change, and effectiveness of the intervention (Kazdin 1980, 2000). Underutilization of interventions among US minority families has been linked to poor perceptions of treatment acceptability (Krain et al. 2005). Parents from different cultures are less likely to employ a skill that is viewed as inappropriate or unacceptable (Forehand and Kotchick 1996).
The BFT procedures include two treatment stages recommended by both HNC/PCIT programs. In Stage I, parents are taught to react positively to age-appropriate child signals in a play context, referred to as “The Child’s Game” (HNC) or “Child-Directed Interaction” (PCIT). Inappropriate attention-seeking (e.g., pout, whine, complain) is ignored, hence, providing a differential attention regimen to motivate age appropriate play and a mechanism to possibly enhance parent–child attachment (Foote et al. 1998). In Stage II, referred to as “The Parent’s Game” (HNC) or “Parent-Directed Interaction” (PCIT), parents are taught to motivate child compliance by the use of clear direct instructions, social reinforcement for compliance, and consistent discipline for noncompliance. Specifically, parents are taught to praise child compliance initiations, warn the child for continued noncompliance, use a chair timeout (TO) system for noncompliance to warnings, and apply room backup procedures to motivate the child to remain on the TO chair. The current study identified nine BFT treatment components for evaluation by Chinese caregivers: contingent praise, responsive play, ignoring deviant attention seeking, authoritative instruction-giving, warnings, chair TOs, ignoring tantrums during TO, room backups for chair TOs, and immediate TOs for aggression (i.e., a “standing rule”).
To date, no studies have researched the acceptability of all the major components of BFT. Nevertheless, quite a few studies have examined the acceptability of several HNC/PCIT treatment components among American samples. Cross-Calvert and McMahon (1987) studied 90 nonreferred mothers of young children ages 3–8 and found rewards, commands, and attends were rated as more acceptable than TO and ignoring. All five HNC techniques, however, were rated very positively. Jones et al. (1998) examined acceptability of six behavioral techniques among 20 mothers of children with disruptive behavior disorder. They found positive reinforcement was rated as a more acceptable treatment technique than response cost, TO, differential attention, overcorrection, and spanking. Masse (2006) found no differences between Native and Non-Native American parents with regard to acceptability of behavioral parenting training. Borrego et al. (2007) found response cost, a discipline procedure, more acceptable than positive reinforcement-based techniques (e.g., differential attention) for Mexican-American parents. Clearly, even among various American samples, there is a difference in opinion about the acceptability of treatment techniques. Nevertheless, even the disciplinary components are found to be acceptable, which is consistent with the application of Stage II interventions which place strict limits on noncompliance and aggression.
The current study is the first to examine acceptability of BFT treatment components among Chinese caregivers. It was predicted that the BFT components would be perceived as acceptable, since increasing child compliance is a treatment goal consistent with Chinese culture. Additionally, mainland Chinese caregivers might perceive differential attention (i.e., contingent praise) as a less acceptable strategy to manage child disruptive behavior, since Chinese parents in Hong Kong were found to be hesitant to use praise in therapy (Ho et al. 1999; Leung et al. 2009). In contrast, the BFT control procedures (Stage II) might be perceived as more acceptable than praise and play components (Stage I), since Chinese families place strong emphasis on conformity, obedience, and discipline (Ho 1986).
Therefore, the purpose of the current study was to examine the social validity of BFT goals and procedures among caregivers in mainland China. First, the perceived ages of deviance of noncompliance, aggression, tantrums, and negative talk were determined by sampling the beliefs of Chinese caregivers. Second, the acceptability of BFT components among Chinese caregivers of young children was evaluated.
Caregivers (N = 183) were recruited from preschools in Hangzhou, a region in East China with a population of about eight million. Caregivers were mothers, fathers, and grandparents from different families and were self-identified as the primary caregiver for the target child. Most respondents were mothers (75%), but some fathers (18%) and grandparents (7%) participated in the study. The mean age for mothers was 32 years (SD = 2.7), for fathers, 35 years (SD = 3.8), and for grandparents, 56 years (SD = 2.6). The caregivers’ education level included: 67% college; 22% high school; 7% middle school; and 5% elementary school. The mean annual household income for the 114 caregivers who reported income was 137,895 Chinese Yuan (about $20,684 US). Children’s mean age was 4.3 years (SD = 1.2). Forty-seven percent of the children were living with grandparents in the 101 families that answered our question about extended kin living with the child. Children were balanced for gender (48% male; 52% female) and virtually all were only children (89%), consistent with the current Chinese culture.
Data collected included caregivers’ age, relation to child, education, and annual household income, as well as the child’s age, sex, siblings, and extended kin living with the child.
Perceived Deviance Questionnaire
Four major BFT target misbehaviors were briefly described: noncompliance, aggression, tantrums, and negative talk. For example, noncompliance was defined as “…willful act of refusing to initiate actions or cease actions when clearly instructed to do so by the parent or other caregivers.” Each caregiver indicated the age at which each misbehavior was perceived to be deviant. “Deviant age” was operationalized as the age by which the misbehavior should no longer occur and should indeed be treated if it persisted.
Treatment Acceptability Questionnaire
Nine specific BFT treatment components were briefly described, along with a rationale for each component’s use. For example, the BFT component “Chair Timeouts” was introduced to Chinese caregivers by stating: “Parents are taught to discipline misbehaviors with brief social isolation (2–5 min) on a timeout chair. Chair timeouts are effective at disciplining misbehaviors in 2- to 7-year olds because the child is briefly removed from all sources of reinforcement (no adult attention, no toys, and must remain on chair).” The nine BFT components evaluated were: Contingent Praise; Responsive Play; Ignoring Deviant Attention Seeking; Authoritative Instruction-giving; Warnings; Chair Timeouts; Ignore Tantrums during Timeout; Room Backup for Timeout; and Immediate Chair Timeouts for Physical Aggression. Caregivers evaluated the acceptability of each component by completing a modified version of the Treatment Evaluation Inventory-Short Form (TEI-SF; Kelley et al. 1989). The original TEI-SF includes nine items that are designed to evaluate the acceptability of a given treatment. The current study used six TEI-SF items that have consistently loaded high on an “Acceptability” factor in Kelley et al. (1989). The key words for the six items are “acceptable”, “willing to use”, “like”, “effective”, “improvement”, and “reaction”. Three of the six items were reverse keyed in the current study to eliminate response bias (i.e., always endorsing the same Likert Scale anchor, such as “Strongly Agree”). The resultant modified TEI-SF, hereafter referred to as the Treatment Acceptability Questionnaire (TAQ) is a 6-item, 5-point Likert scale (where 0 = strongly disagree to 4 = strongly agree). Scores for each treatment component ranged from a minimum of 0 to a maximum of 24, where any average score above 15 reflected minimum acceptability, since 15 was half way between an average item acceptability rating of “Neutral” and “Agree”. The alpha coefficients of the TAQ for the 9 treatment components ranged from .79 to .91.
The average age at which the four targeted misbehaviors were perceived to be deviant were: noncompliance 3.5 years (SD = 1.4); aggression 3.4 years (SD = 1.3); tantrum 3.7 years (SD = 1.6); and negative talk 4.1 years (SD = 1.7). A 4 (misbehaviors) × 3 (caregivers) repeated measures ANOVA revealed a significant misbehavior effect, F(3, 377) = 3.99, p < .01, indicating that the perceived ages of deviance were significantly different. Post hoc least significant difference (LSD) comparisons indicated that aggression was considered deviant at a younger age than both tantrums and negative talk.
Treatment acceptability of BFT components across Chinese caregivers
Mothers (n = 135)
Fathers (n = 33)
Grandparents (n = 12)
Ignoring in timeout
This study sought to examine the social validity of BFT among caregivers in China, focusing on treatment goals and acceptability of treatment procedures. Chinese caregivers agreed with BFT treatment goals in that they perceived child noncompliance, aggression, tantrum, and negative talk to be deviant by 3–4 years of age. Chinese caregivers considered praising good behavior and responsive play to be the most acceptable treatment procedures, while room backups for chair TOs were the least acceptable; no treatment procedure was considered unacceptable (i.e., all mean acceptability ratings were above the neutral point of 12 on the Likert scale).
The finding that these Chinese caregivers considered continued noncompliance, aggression, tantrums, and negative verbalizations after the age of 3–4 provides support for the potential utility of BFT in China. The Chinese perceived age of deviance around 4 years old is within the 2–7 years age range for the HNC/PCIT treatment protocol, which suggests Chinese caregivers’ beliefs are consistent with BFT goals. If it were known to Chinese caregivers that disruptive child misbehavior can be effectively managed and that effective services were available, Chinese parents with defiant, coercive 4-year olds might readily avail themselves of such services.
Moreover, Chinese caregivers perceived BFT treatment components to be acceptable. Differential degrees of acceptance, however, were detected among the nine components. Chinese caregivers considered positive strategies (i.e., socially reinforcing compliance and general responsivity during play) more acceptable than the other seven BFT components. This finding is consistent with data from European American caregivers (e.g., Cross-Calvert and McMahon 1987; Jones et al. 1998). However, this finding contradicts the reports that Chinese parents in Hong Kong are hesitant to use praise (Ho et al. 1999; Leung et al. 2009). Results from current study suggest that mainland Chinese caregivers find contingent praise and responsive play at home to be acceptable parenting strategies.
In contrast, the more disciplinary components of BFT received relatively low ratings. This could be a major barrier to treatment utilization if not accommodated in some manner more consistent with Chinese child care practices. In European-American culture, enforcing chair TOs with room TOs appears to be an important treatment component for overtly noncompliant children (Roberts 2008). Overtly noncompliant preschoolers fiercely resist initial chair TOs (Roberts 1982). If parents allow noncompliant children to escape from chair TOs, compliance acquisition is significantly attenuated (Bean and Roberts 1981; Roberts and Powers 1990). Room backups to chair TOs (Day and Roberts 1982; Roberts 1988) have successfully replaced the spanking contingency used by Hanf (1969), whose program served as the basis for the modern HNC and PCIT programs. Most importantly, noncompliant, TO resistant young children in European-American samples quickly adapt to the contingencies and rarely even require a chair TO, let alone a room TO backup, after the first month of home use (Roberts and Powers 1990). Despite the apparent need for a disciplinary treatment component, parents in European-American cultures also rate TO and the associated backup systems relatively poorly (Cross-Calvert and McMahon 1987). Nevertheless, participants in BFT programs tolerate the disciplinary procedures and strongly embrace the programs in general (e.g., Forehand et al. 1980; Schuhmann et al. 1998).
What treatment accommodations might exist for a Chinese constituency? Parent concerns about child safety and trauma in room TO backup (Yu and Roberts 2010) might be related to housing conditions and parenting practices in China. Most Chinese families in cities and towns live in tall buildings with relatively small apartments, yielding a potential TO backup room cluttered with objects. Under such TO conditions, angry young children might act in a dangerous, destructive, or self harming manner, heightening caregivers’ concerns about children’s safety. Moreover, Chinese caregivers rarely leave young children alone, even during sleep. Wang et al. (2008) found that 62% of Chinese children under age six sleep with their parents in the same bed and 25% sleep in the same room. One possible accommodation might embrace a fading procedure using the parent’s proximity to reduce child fears and parental concerns about brief social isolation in a backup room. For example, if the child attempts to escape the TO chair, the parent could guide the child to the bedroom and stand silently and authoritatively inside the room by the door. In addition, the parent’s proximity could be gradually faded from within touching distance to the more typical line-of-sight in the same room. Apparently, parents could be provided with these or other options; and as in all BFT programs, home data could be used to inform parent and therapist if adjustments are needed.
A small set of caregiver differences were present in our data set. Chinese mothers found contingent praise more acceptable than grandparents, and mothers rated ignoring deviant attention seeking more acceptable than fathers. The difference among caregivers would have to be addressed by therapists, since inconsistency among caregivers is a risk factor for child misbehavior (Wei et al. 2007) and is likely to adversely affect the outcome of BFT. In addition, Chinese children cared for by grandparents have shown more behavioral problems than those who were under parental care (Wei et al. 2007). Considering the fact that 47% of children in our sample lived with grandparents, any inter-generational or inter-caregiver disagreements must be resolved prior to implementation of a therapeutic routine.
Several limitations should be considered when interpreting the findings of this study. First, our sample was recruited from the community of Hangzhou. They were not caregivers of clinic-referred children with disruptive behavior problems. Clinical populations in China might evaluate BFT components differently. Second, the majority of our sample was college educated. It is important to gather more information regarding BFT evaluations in samples with less education. Third, only one caregiver from a family participated. It may be useful to collect data from multiple caregivers, as caregivers from the same family may have different opinions regarding the acceptability of BFT. Finally, BFT components were evaluated in isolation. Were caregivers to rate each component upon completion of the entire treatment protocol, a different picture might emerge. Nevertheless, the current study found that Chinese caregivers agreed with European American parents that persistent noncompliance, aggression, tantrums, and negative talk in parent–child interaction should gradually cease during the preschool period. Moreover, treatment components of the empirically supported HNC/PCIT protocols were judged to be acceptable, albeit with relative preferences for more positive parenting strategies. Therefore, it appears culturally acceptable to perform clinical trials using HNC/PCIT treatment components in China where to date, no such programs are available, despite apparent need. Certainly, all applications of any treatment protocol must consider individual and cultural differences which would guide accommodations like those discussed above.
Part of this data was presented as a poster at the World Congress of Behavioral and Cognitive Therapies, Boston, MA, USA, June 2010. The authors thank all the volunteer participants and the following individuals for their assistance to the project: Guozhen Cen, Yiyuan Xu, Linyan Su, Luyi Du, Xiaojuan Wei, Xuzhen Ma, Yazhen Zhou, Chengfeng He, Guobing Zhang, Hao Yu, Xiaoxian Gan, and Fang Chen.