Group Parent Training with Immigrant Chinese Families: Enhancing Engagement and Augmenting Skills Training

Abstract

Parent training (PT) is a well supported treatment for reducing and preventing child conduct problems and abusive parenting. However, questions have been raised about the dissemination of PT to culturally diverse families who hold different views on childrearing and family structure. This article describes the application of group PT in two Chinese immigrant families to illustrate dual strategies for addressing potential cultural barriers. The Incredible Years program builds in many therapeutic process elements to address cultural concerns about PT skills to enhance parental engagement. In addition, augmenting basic PT with additional skills training can help parents manage stressors common in immigrant families in order to facilitate uptake of new parenting skills. Our implementation experience suggests that high risk immigrant Chinese parents can be effectively engaged in group PT even when they are not in treatment voluntarily.

Parent training (PT) constitutes a well-established class of psychosocial treatments for reducing child conduct problems (Eyberg, Nelson & Boggs, 2008). PT boasts some evidence of generalizability from clinical trials that included culturally diverse samples. For example, Parent-Child Interaction Therapy is efficacious in reducing abusive parenting among White, Latino, and African-American families, with no treatment by ethnicity interactions (Chaffin et al., 2004). The Incredible Years program, for another example, has reduced child conduct problems in prevention samples including White, Latino, African-American, and Asian-American families, with few ethnic differences in attrition and outcomes (Reid, Webster-Stratton, & Beauchaine, 2001).

At the same time, cultural barriers interfere with the implementation of PT. Parents are required to modify their childrearing in ways that may be incongruent with their cultural values and traditions (Forehand & Kotchick, 1996). For example, Asian American parents who hold Confucian based values may object to positive reinforcement systems that require parents to provide children with tangible rewards for performing specific behaviors. The edict of filial piety dictates that children should obey parents as authorities as a matter of obligation and duty; reinforcement within a system of agreed upon terms may be seen as inconsistent with the expected hierarchical family structure. Disparities in engagement and efficacy of PT among ethnic minority families have led to efforts to adapt PT to increase cultural responsiveness (Lau, 2006).

In this article, we illustrate cultural barriers that may arise in the implementation of PT with Chinese immigrant families and how these barriers have been effectively addressed in our work.

Parent Training with Asian Americans

Asian Americans are among the most underrepresented ethnic minority groups in psychotherapy research (Miranda et al., 2005). However, small wait-list controlled trials with Chinese and Korean American parents suggests that PT can be delivered with efficacy for these immigrant groups (Kim, Cain & Webster-Stratton, 2008; Lau et al., in preparation). International trials involving Chinese parents in Hong Kong and Australia have likewise demonstrated efficacy of PT (e.g., Crisante & Ng, 2003; Ho et al., 1999; Leung, Sanders, Leung, Mak & Lau, 2003; Leung, Tsang, Heung & Yiu, 2009). Given this level of research support, PT is among the most well established treatments for Chinese families, and as such could be considered a first-line treatment to address childhood externalizing disorders among Chinese-origin families.

Yet, cultural barriers complicate the implementation of PT with Chinese-origin families, indicating the need for cultural adaptation (Lau, 2006; Lau, in press a). The most well documented disparities in PT involve poorer engagement of ethnic minority families, rather than disparities in efficacy when an adequate treatment dose is received (Lau, 2006). In trials evaluating PT, recruitment rates are lower, drop out rates are higher, and active participation is less frequent among immigrant and ethnic minority parents compared to Whites (Reid et al., 2001; Cunningham et al., 2000, Holden, Lavigne & Cameron, 1990, Kazdin & Whitley, 2003, Orrell-Valente, Pinderhughes, Valente, & Laird, 1999). Thus, culturally adapted parent training are designed to increase engagement (e.g., McCabe et al., 2005).

Barriers to engagement in PT are likely to be greatest among Chinese immigrant parents with low levels of acculturation who are mandated to treatment (Ho et al., under review). Some barriers may originate from misgivings about PT strategies involving in differential reinforcement, owing to specific values and beliefs. Our research suggests that some Chinese American parents hold beliefs about motivation that contraindicate praise and favor criticism (Lau, in press a). The frequent East Asian belief that “children will stop trying hard if you praise them” highlights a self-improving orientation in which criticism of performance motivates persistence among East Asians, while Americans tend to hold a self-enhancing orientation that prioritizes maintaining self-esteem (Heine et al., 2001). Like other groups, Chinese American parents often object to the strategy of ignoring misbehavior because of the potential for loss of face by failing to correct shameful child behavior swiftly and publicly. Culturally competent PT must responsively address concerns about cultural incongruence of techniques.

However, motivational enhancements to address cultural concerns among immigrant Chinese parents may not be sufficient without highly supportive instruction in novel techniques. Even when reticence or resistance is overcome, motivated immigrant parents may still encounter difficulties in acquiring PT skills. Immigrant Chinese parents may require additional support in learning techniques because they are culturally foreign (Lau, in press a). Modeling, enactment, rehearsal, and monitoring of parents use of PT techniques is essential. Thus, engagement must involve (1) exploring cultural misgivings about PT, (2) cultivating a working alliance to motivate change toward the parents’ valued goals, and (3) supporting acquisition of culturally novel parenting behaviors.

Previous trials of with immigrant families suggest that an increased dose of PT may be necessary to reach skill mastery (Matos et al., 2006; McCabe & Yeh, 2009). This may be attributable to difficulty “buying into” culturally unfamiliar techniques or requiring more practice to master novel skills. Ho and colleagues (1999) noted that once initial resistance to using praise was overcome, there was still considerable difficulty in teaching Hong Kong Chinese parents to praise their children. They found it necessary to bolster their instruction with the use of videotaped feedback and immediate reinforcement with live coaching. Some parents refused to praise, but those who tried used praise in a ‘mechanistic and unemotional manner’ limiting its effectiveness. Likewise, Chinese-Australian parents needed extended practice of the unfamiliar behaviors of giving and receiving praise in role-plays until they better understood the intention to evoke positive affect (Crisante & Ng, 2003). This line of research indicates that PT can be effective with Chinese parents when barriers to engagement are addressed and behavioral rehearsal is buttressed.

Another approach to increasing the cultural responsiveness of PT has been to address specific risk factors for parenting or behavior problems in immigrant families. Martinez and Eddy (2005) adapted PT for Latino immigrant families to address problems associated with differential acculturation between children and parents. Psychoeducation and communication training were introduced to reduce intergenerational conflicts that derail effective parenting.

Our research indicates that children’s school problems are strongly associated with harsh physical discipline among Chinese immigrant families, and that parent-child acculturation conflicts were related to physical discipline when parents held traditional values about firm parental authority (Lau, in press b). In our work, immigrant families experiencing these specific types of cultural clash often presented for treatment following a child protective services (CPS) investigation for suspected abuse. Thus, for these high-risk immigrant Chinese families we augmented PT with skills training to reduce the burden of contextual stress to permit parents to follow-through with new, effective strategies.

Our cultural adaptation of PT for children’s school problems involved three augmentations. First, cognitive restructuring help parents to control upsetting thoughts about children’s bids for autonomy and school problems that lead to ineffective parenting (e.g., blaming attributions that lead to overly punitive discipline or helpless thoughts that lead to inconsistent discipline). Parents are taught to replace upsetting thoughts with non-blaming, self-efficacious thoughts that mobilize effective behavior management. Second, psychoeducation and communication skills training help parents reframe and resolve recurrent acculturation-related conflicts. These are framed as bicultural parenting skills that address the special needs of the immigrant family. Parents are taught active listening skills and problem-solving steps to elicit the child’s perspective on the problem, communicate their own concerns effectively, collaborate in generating a variety of solutions, evaluate the options, make a plan, and monitor the results. Third, to prevent punitive responses to school problems, parents are taught to increase positive involvement in children’s schooling -- showing interest in what their child is learning, structuring the homework routine, and limiting (television and computer) screen time. While attending to the needs of parents with limited English, parents are taught how to support study skills and coach persistence in the face of academic difficulties. Parents are also taught how to communicate effectively with teachers to proactively address challenges their children encounter in school.

We implemented the Incredible Years (IY) parenting program with immigrant Chinese American parents of school-aged children referred by schools, clinics, and CPS. The IY BASIC modules focus on core skills based on social learning principles (e.g., child-directed play, praise, rewards, ignoring misbehavior, time out, consequences). The ADVANCED modules teach supplemental skills including communication training, cognitive restructuring, and problem-solving steps to meet the needs of parents with ancillary stressors. We assembled a 14-week IY protocol with content tailored as described above and as summarized in Table 1.

Table 1.

Session Schedule of the Incredible Years (IY) parenting program with immigrant Chinese American parents

Session	Topic	Goals
1	Parental attention	Giving positive attention to appropriate behavior Spending special time with children to promote closeness Child-directed play to show interest and model compliance Avoiding unnecessary commands Descriptive commenting
2	Effective praise	Reducing commands and criticism Specific, labeled, immediate praise to increase desired behavior Identifying and praising a target behavior
3	Tangible rewards	Effective incentives Sticker charts and point systems Explaing reward systems to children, monitoring progress
4	Clear limit-setting	Transitions and warnings Effective, clear, polite commands Following through with commands
5	Ignoring misbehavior	Ignoring protests and negative attention seeking Avoiding arguments Selective ignoring
6	Controlling Upsetting Thoughts	Identify negative thoughts that lead to ineffective parenting Stopping negative self-talk Replace with positive self-talk
7	“Time Out”	Explaining time-out to children Time out for non-compliance Back-up consequences Trouble shooting time out
8	Logical consequences	Warnings for logical consequences Identifying appropriate and logical consequences Loss of privileges Follow through with consequences
9	Problem-solving	Family meetings Problem solving steps, generating solutions as a family Planning and evaluating solutions
10	Family communication	Active listening Making polite requests Talking about feelings Perspective taking
11	Learning routines	Setting up a predictable homework routine Limiting TV and computer time, following through with limits Praise and encouragement of learning
12	School encouragement	Showing interest in school work Praising children for effort Encouraging persistence
13	Solving school problems	Communicating with teachers Advocating for children Working with teachers to solve problems
14	Review and Goodbye	Review important strategies Review parents’ progress toward goals Plans for continued support of positive parenting

IY incorporates many features that may promote cultural sensitivity by introducing skills in a collaborative rather than didactic manner (Webster-Stratton, 2007). As each skill is introduced, parents discuss the benefits and barriers to using the skill while the group leader actively explores its cultural and practical barriers. The group leader encourages engagement by drawing parallels between the benefits of the technique and parents’ stated goals. In each session, videos of parent-child interactions are viewed, and the group leader facilitates a discussion in which the parents construct the principles underlying effective parenting. Treatment manuals orient group leaders to common concerns about each PT skill (e.g., concerns that praise will ‘spoil’ children, worries that time-out is not punitive enough). Group process leverages peer-to-peer instruction and experiential learning, such as praising and rewarding parents in session as they are instructed to do with their children. Rehearsal is emphasized, with role-play, and close monitoring of session homework. Practical barriers to treatment are also addressed in IY. Recommended implementation of IY also includes providing family meals before group and child care during group. This permits working families to attend PT without the added stress of preparing meals and supervising children’s homework on busy a weeknight. Thus, IY program builds in multiple, effective strategies for enhancing engagement for Chinese parents.

In the following sections, we apply these principles of cultural adaptation of PT with two immigrant Chinese families referred to treatment by children’s protective services (CPS) for suspected maltreatment. Both cases illustrate the value of initial engagement processes to overcome cultural misgivings about PT as well as mistrust and stigma associated with involuntary treatment.

Case 1: The Chen Family

Presenting Problem and Client Description

Diana (age 36) and Tom Chen (age 39) immigrated from China 15 years ago. They now have 2 children: a 12-year old son, Richard, and a 6-year old son, Charles. The family lives in a quiet middle-class suburb East of Los Angeles. The family speaks Mandarin at home, but the children and Tom are fluent in English and speak English exclusively outside the home. Diana works part-time in a retail store serving Chinese clientele and has limited English proficiency. Tom works as an engineer with management responsibilities working at a mid-size firm. There was no known family psychiatric history, and neither parent had previously received treatment, nor were they receiving other treatment concurrent with PT.

Diana reports strong relationships with her children, though she feels that her relationship has been strained recently with Richard. Despite doing very well academically, Diana and Tom report that Richard is irritable and often oppositional at home. There was significant sibling conflict between Richard and Charles, which Diana reported being difficult to manage. Several weeks prior to treatment, Richard’s teacher noticed bruises on his arm. Upon inquiry, he told his teacher that his father had punished him for not listening. A CPS report was made, and the investigating social worker noted that Tom had struck Richard for talking back after he was told to stop playing a computer game to begin his homework.

At the commencement of treatment, Tom and Richard were highly estranged from one another. Tom was incensed at his son for reporting the incident and stated, “Since he won’t accept my discipline when he misbehaves, then I’ll just let the State and his mom do the parenting…I don’t want to have anything to do with him.” The two were no longer on speaking terms, and Tom would not even acknowledge Richard’s presence. Diana was distraught and disapproved of Tom’s overt rejection of Richard. However, she did share in Tom’s resentment and felt helpless to address Richard’s talking back and defiance.

Case Formulation

Tom and Diana grew up in China holding traditional Chinese values of filial piety and accustomed to a hierarchical parent-child relationship. They expected submission, respect, and high achievement from their children. Richard did excel in school, and Tom and Diana viewed this as his duty. Diana also expected Richard as the older child to set a proper example for his younger brother, to care for and be patient with him as additional caregiver. She described this with the Chinese idiom da rang xiao, meaning that the older child should accommodate the younger child and assume responsibility for their misbehavior. Diana also conformed to the traditional notion of guan, which encompasses self-sacrificing and devoted mothering to promote good conduct through continual monitoring, correction, and physical closeness.

Tom was particularly angry with Richard for reporting corporal punishment resulting in the CPS abuse allegations. He felt betrayed by his son who he had expected to honor him. He felt attacked and discredited by the CPS and the social workers who undermined his authority in the family and community. The child abuse allegation was a disgrace to the family, causing Tom to “lose face.”

Tom and Diana felt that Richard’s recent noncompliant and disrespectful behavior called for punitive measures in discipline. They stated that Richard had previously been the perfect child, obedient, polite, and hardworking. They were puzzled by his recent behavior and did not draw connections between the nature of their interactions with him and his behavior, as well as the possible contributions of their da rang xiao approach to handling sibling rivalry. They did not recognize that Richard may require positive attention for prosocial conduct and school achievement in order to maintain those efforts. They saw Richard’s behavior problem as resulting from poor character: he was simply stubborn, hot-tempered, and untrustworthy.

Course of Treatment

Both parents were resistant to engaging in the PT group, feeling that their parental authority had been undermined. Tom related, “We can’t even discipline our own kids in the U.S. when they’re going the wrong way. If he doesn’t want us to help him, he can do whatever he wants. I’ll just leave him on his own.” They felt that the problem was Richard, and that treatment should focus on the “problematic” child. In the first two sessions focused on foundational skills in positive attention, Tom was guarded and distant, he did not participate in group discussions. Diana was more engaged, but repeatedly stressed that Richard should be the one in treatment, adamant that PT would not be effective” “Someone needs to teach this 12-year-old to change his behavior.”

During the first 2 sessions group leaders focused on teaching the attention principle -behaviors that gain parental attention will increase in frequency. Diana and Tom were encouraged to acknowledge Richard when he complied with requests at home. Both parents expressed doubts that increasing positive attention and praise would be effective in improving Richard’s behavior. In the discussion of the benefits and barriers to praising children, Diana described the dangers of re-structuring the parent-child relationship to be less hierarchical.

Diane: Ever since Richard was young, whenever I play with him or praise him, he would start acting up and take advantage of me. It’s like he thinks he’s got me wrapped around his finger.

Group leader: Sounds like you are concerned that positive attention makes Richard misbehave more because he loses respect for you.

Diane: Yes, I’m scared of that. I’m not close to him, I have kept my distance from him. That way, it’s easier to teach him and he’s much better behaved. Praise isn’t necessary. Everyone should understand that if you love me and behave, then I will love you back.

In order to address their resistance and to begin to help the parents mend their relationship with Richard, group leaders were conscientious in processing the cultural barriers hindering engagement in the curriculum. Group leaders focused on developing trust with parents by showing empathy and commenting on the struggles of cultural adjustments in parenting. Through group discussion with parents with similar concerns, group leaders normalized Tom and Diane’s feeling of disgrace, and the stress of having their good faith efforts be characterized as abusive by CPS.

Diane: Cultural differences are big. At home, education is Chinese style, then at school it’s American style…they adjust faster than we do. I don’t know what to do.

Group leader: Yes, it’s really difficult for immigrant parents to adjust to and accept the values that their kids are growing up with here in U.S. It was different for us growing up overseas. In this new setting, immigrant parents often find they need new tools for communicating with their children. Children are accustomed to positive attention and relationships can suffer here without acknowledgement. It’s not like how we grew up.

In each session, group leaders led discussions so that principles of effective parenting are elicited from the parent participants. Leaders wrote each parent’s comments down, ascribing the idea or principle to that parent each time it was discussed next. For example, “Diane’s tip is that ‘Play should follow the child’s lead’”. In later discussions of the videotaped vignettes, role-plays, and homework assignments, group leaders would remind parents of Diane’s rule for ‘following the child’s lead.’ This helped parents take ownership of PT skills, and in particular, helped Tom and Diane re-build their confidence in parenting competence after the CPS allegations.

When group leaders commended Tom and Diane for Richard’s continued academic success they suggested that effort in schoolwork could be a target of praise, Diane and Tom and others objected. The group leaders validated this cultural concern and underscored the importance of praising effort:

Tom: Kids should do well in school and study hard. Why should we praise them for what they are supposed to do?

Another group member: Yes, kids will get too puffed up and proud.

Mr. Li: I don’t understand why I should reward things they should already be doing. Studying hard is a normal responsibility. Listening to parents is simply a must. Why should they feel proud when they are merely meeting a basic obligation?

Group Leader: Chinese parents are actually right in this belief. Children may indeed stop trying when praise focuses on children’s abilities, like if you just tell them ‘you are so smart’. Instead, specific praise has to focus on the child’s effort (for example., I am very proud of how hard you tried on that tricky math problem). This kind of praise can increase persistence, something we can all agree is important.

Group leaders helped Tom and the other parents reconcile their cultural views on the downside of praise with the lessons of how to avoid these pitfalls to use effective praise. Global praise can cause kids to lose humility, but labeled praise can be used to increase specific behaviors children. Parents formed pairs and spent a few minutes coming up with specific ways to praise their child’s good efforts.

Role play is an essential component of PT, indispensible for enacting new and culturally foreign strategies. With concerns about potential loss of face in mind, group leaders are taught strategies to maximize parents’ success in a role play. Group leaders invite specific parents to role play first, selecting those who appear more extraverted and engaged. In beginning role plays, group leaders coach the parent through the role play, whispering things to do and say. This support is tapered off as parents gain experience and confidence in PT. Parents are praised and given rewards following each role play. Though Tom was reluctant initially, since everyone else in the class took a turn, he also participated in role play beginning in the second session.

Role play was also used to illustrate relational conflicts and address cultural barriers to PT. To help Tom and Diane understand the impact of their approach to disciplining Richard, group leaders set up a role play to help them build empathy for their eldest son. Tom was assigned to act as the older sibling of two siblings playing with their mother, portrayed by Diane. Diane was instructed to attend to and praise the behavior of the younger child. Tom was instructed to seek attention through complaining and was quieted by the mother, saying Da rang xiao. Group leaders processed the role play:

Group leader: How did you feel when the Mom only paid attention to the sister?

Tom: It made me feel like not wanting to try anymore since I’m not being appreciated.

Throughout the sessions, group facilitators continued to model effective praise of each group member’s efforts and participation. Parents were instructed to practice the new skill of praising their spouses and others outside the group. When reporting on their Session 5 homework on Ignoring Misbehavior, Diana related that she had been unable to suppress her annoyance at Richard’s protesting. She then went on to praise Tom for having remained calm, and recounted instances where he ignored Richard’s protests and reminded her to use active ignoring. Group leaders and group members alike commended Tom for his uptake of this strategy. One group member commented, “Tom and Diane are showing all of us that we can affirm and support each other.” Praise amongst group members fostered a supportive alliance and excellent group climate. By Session 8, Diane reported that Tom had begun to reconnect with Richard, as he warmed to the idea of providing positive attention for Richard’s cooperative behavior. By Session 11, Tom and Diane were holding family meetings with their children to generate solutions for routine problems such as handling arguments between siblings.

Outcomes and Prognosis

Over the course of treatment, Diane showed a 65% decrease in negative discipline on the Alabama Parenting Questionnaire and a 10-point decrease in her score on the Parenting Stress Index-Short Form. These scores placed her below the clinical range at post-treatment.

Case 2: The Li Family Presenting

Problem and Client Description

Mrs. Yan Li (age 46) and Mr. Jung Li (age 47) were referred to parent training by their CPS social worker following an alleged incident of child physical abuse. Mrs. Li is a full-time homemaker who self-reported a history of depression with suicidal ideation during adolescence, but no current mood disorder symptoms. There is no other known family psychiatric history, and Mrs. Li had not previously received treatment for depression, nor was any family member receiving treatment in addition to PT. Mr. Li is a small business owner importing merchandise from China. Mr. Li’s business requires him to be out of the country periodically. Mr. and Mrs. Li speak Mandarin and have very limited English proficiency. Mr. Li’s business is conducted exclusively with Mandarin speakers. They are both college educated and live in an affluent, predominantly Chinese suburb east of Los Angeles. The couple has two children, an 8-year old daughter, Cindy, and a 14-year old son, Li Xian. The Li family moved to Los Angeles from Hunan, China approximately 18 months prior to entering treatment.

Mr. and Mrs. Li related that Cindy had been having problems adjusting in school. When she began the second grade, she screamed and cried frequently and experienced anxiety separating from her parents at drop-off. Teachers reported that Cindy had difficulty making friends. Mr. and Mrs. Li reported that her tantrums were increasing rather than decreasing with age, and Cindy had once talked about wanting to harm herself. Mrs. Li felt that Cindy needed constant attention and was argumentative about getting her way. Cindy and her brother, Xian, also did not get along and argued frequently.

Mr. and Mrs. Li acknowledged that their parenting practices with their son were not working currently and they felt there was an increased emotional distance between them. Xian was adjusting quickly to American culture and school, but their daughter was having major adjustment difficulties. They felt that their daughter was not responding to their parenting and they didn’t feel equipped to help her. Mr. Li did not feel he understood his daughter’s struggles and felt unsure how to support her. He felt his own transition to American culture was going slowly, especially with learning English. Mr. and Mrs. Li also felt a growing emotional distance between them and their adolescent son, Xian, with whom they spent little time. Xian was making friends, spending time on the computer, communicating only minimally with the family, and learning English more rapidly. Mr. and Mrs. Li were concerned that Xian was not focused on his studies.

Case Formulation

Mr. and Mrs. Li agree that the main reason they came to the U.S. was so their children could get the best education. Indeed, they chose where to live on the basis of the strong reputation of the public school system. However, Mrs. Li found herself feeling helpless in this transition, unsure about how the system works, and how she should support Cindy with her adjustment difficulties. Mrs. Li viewed her daughter’s behavior as revealing a lack of security and confidence in this new context.

In addition, Mr. and Mrs. Li entered treatment with a visibly strained marriage. Mr. Li spent a lot of time away from home given his business demands and, when present, Mrs. Li complained that her husband was demanding and hostile. She began to second guess Mr. Li’s decision to move the family. She had few friends in Los Angeles and felt isolated and resentful about her husband’s frequent absence. Mrs. Li took care of the household and prepared the family meals, but would then retreat to her room after dinner.

The Li parents and children were encountering acculturation stress, albeit each with differing manifestations. Cindy with separation anxiety, Xian struggling to individuate and feeling estranged from his family. Mrs. Li’s feelings of helplessness, isolation and resentment were preventing her from generating effective strategies to support her family in this transition. She was unsure what to do next in this crisis. Her withdrawal from her family is consistent with her history of depression and exacerbates this acutely stressful period. Mrs. Li is ambivalent about the immigration and transition may have compromised her ability to support her daughter’s separation at school. Mr. Li felt his parental and patriarchal authority was slipping and in response, his punitive approach with his son and anger toward his wife were escalating. Mr. Li filtered each negative interaction with any of his family members as evidence of a fundamental lack of respect and discipline.

Course of Treatment

Mr. and Mrs. Li arrived for the first session with Cindy, who cried and screamed when the family meal concluded and it was time for her parents to attend the group PT session. The child care workers had difficulty distracting Cindy, who chose to stand outside the meeting room through much of the 2-hour group. During the session, Mr. Li appeared disinterested, sitting outside the semi-circle of chairs, and declining invitations to join the group. He repeated “I’m just here to observe and I’m not interested in participating.” Mrs. Li was also quiet, though responsive to questions. Regarding goals for the program, Mrs. Li reported that they wanted to “learn ways to communicate with the school and to help their children.” Mrs. Li voiced her frustration of not knowing how to navigate the American school system and also expressed worries about Cindy’s behavior problems. With her teenage son, Xian, she said she doesn’t know how to communicate with him so that he doesn’t continue to stray from them.

Group leaders praised Mr. and Mrs. Li for their commitment to their children and empathized with their concerns, normalizing these stressors commonly faced by immigrant parents. Group members reached out to the Li’s when they learned how recently they had immigrated and shared stories of their own initial adjustment difficulties. Mr. Li was given space to join the group on his own terms. Group leaders made a point to thank him each week for attending whether or not he participated, and patiently encouraged his involvement. When, on occasion, Mr. Li was observed to whisper his opinion to his wife, group leaders expressed curiosity and invited him to share his thoughts with the group. The group listened attentively and appreciatively.

By the 4^th session, Mr. Li showed noticeable improvement in treatment engagement. He joined the rest of the parents in the semi-circle of chairs and became more responsive during session. Ultimately, he attended every session, was always punctual, and expressed an eagerness to apply PT strategies in his daily interactions with his children.

To address the notable strain in the relationship between Mr. and Mrs. Li, group leaders worked on generalizing lessons on positive attention and praise. In the fifth session, Mrs. Li noted that she had been faithfully spending 15 minutes a day playing with Cindy after dinner. She noticed a qualitative change in their relationship and reported a decrease in tantrums as monitored in the previous weeks. Mr. Li interjected and pointed out that his wife did not do her homework entirely correct because she directed most of the play activities rather than following Cindy’s lead. Prompted by another parent in the group, Mr. Li caught himself being critical and turned to offer praise to his wife: “Thank you for playing with Cindy even though I know you are sometimes tired and don’t feel like it.” Group leaders praised both Mr. and Mrs. Li and helped them brainstorm play activities that would be more child-directed.

In session 5, Mr. and Mrs. Li were asked to apply differential reinforcement and active ignore strategies to reduce the frequency of Cindy’s tantrums and protests at separations. Mrs. Li had difficulty following through; she felt drawn to comfort her distress at school drop-off and attend to her other protest behaviors throughout the day. Group leaders acknowledged that it is very difficult for parents to see their child so upset. Other group members encouraged Mrs. Li to keep trying and reassured her it would be better not to linger and simply say, “Ma Ma will be back to pick you up right after school, you’ll be fine here.”

Beginning in session 6, parents were taught to use positive self-talk in order to manage their upsetting thoughts. Group leaders talked about learning to recognize and cope with negative thoughts and feelings (e.g., anger, depression, and guilt) that de-rail effective parenting. Mrs. Li identified her own fear that Cindy would not fit in at school as an obstacle to her effective parenting. She acknowledged her thoughts that her daughter “needs her because going to school was too stressful.” Other parents in the group reassured and supported Mrs. Li by sharing their experiences having watched their children succeed through the transition. Group leaders encouraged her to replace her upsetting thoughts with ones that would allow her to follow through with an effective strategy. Whenever Cindy had a tantrum or cried at separation, Mrs. Li was encouraged to say to herself, “This will pass.”

Likewise, Mr. Li explored cognitions that interfered with his adopting new approaches to dealing with Xian. He discussed his growing frustration as Xian refused to join the family at the dinner table during meals, choosing to spend the majority of the time in his room playing video games or browsing the internet. When Xian did emerge from his room, he often wore headphones. Mr. Li felt disrespected and angry. Group leaders guided Mr. Li in identifying the thoughts that made this behavior so upsetting.

Mr. Li: Xian knows how important it is to me to eat together as a family and that I don’t like to see him with his headphones on. He is doing it on purpose to make me mad.

Group leader: Oh, so it is these thoughts that are at the root of why you get so angry. Of course, we would all feel upset if we believed our child was trying to irritate us on purpose. When we assume we know why our child is behaving a certain way, we call it “mind-reading”

Other group members offered alternate assumptions to explain Xian’s behavior that would not breed resentment towards Xian. For example, teenagers constantly listen to music to relax and enjoy themselves. Mrs. Li then shared her own negative self-talk.

Mrs. Li: I see how he is and I just say, I can’t talk to him. Why bother try? He’s too old to listen to us. Nothing will work.

Group leader: So when you have these thoughts, that’s when you withdraw from Xian, believing that the situation is beyond your control.

Mrs. Li: Yes, and sometimes I blame myself. I always doubted the decision to bring our family here [to the U.S.]. That also makes me just want to give up.

Once Mr. and Mrs. Li learned to identify blaming and helpless attributions for their children’s problems, they were encouraged to substitute them with more calming and self-efficacious thoughts. Mr. Li was encouraged to focus on the behavior he wanted to encourage rather than speculating about his son’s ill motives. Group leaders helped him follow through on a plan to invite Xian to the table, explore his reluctance to join the family, and generate solutions for this problem. Mr. Li was encouraged to substitute his blaming thoughts with positive self-talk: “There are things that I can do to improve my relationship with Xian. It just takes time”

Group leaders highlighted the importance of parental self-care and being aware of one’s own responses to stressful events and thoughts. Parents were encouraged to give themselves a Time Out to release tension and gain control over their emotions. Mr. and Mrs. Li discussed how they might give each other time to cool down without compromising child care responsibilities. They later shared with the group leaders that they found this session particularly useful in helping them handle their daily tensions.

In session 7, group leaders introduced skills related to perspective-taking, open communication with children, and effective problem-solving strategies. Mrs. Li shared an incident in which Xian picked up Cindy from school and she had a tantrum, screaming and running away. Xian had to chase after her. Xian was exasperated and refused to pick her up again. Mr. Li “gave them each a lecture on their responsibilities.” The group leaders discussed how Mr. and Mrs. Li could apply the communication skills and problem-solving steps to address this incident. The Li’s were coached through a role play on how to encourage each child to state the problem and express their feelings about it toward the goal of seeing the other person’s point of view. The Li’s role played how to validate and empathize with Xian’s frustration, reflecting that the situation was very difficult to handle. Unassisted, Mrs. Li role played asking Cindy, “Do you know how your behavior makes Ge Ge feel? If you were the Jei Jei and your Di Di did this to you, how would that make you feel?” The Li’s reported that the role play helped them stop and think about Xian’s feelings.

Group leaders presented the problem solving steps: 1) problem definition, 2) brainstorming, 3) evaluating solutions, 4) making a planning, and 5) checking to see if it worked. Mrs. Li predicted that, if they talked to Xian this way, he would be more willing to come up with solutions and find an arrangement where he would continue to occasionally pick up his sister. But, Mr. Li pointed out that this approach was a big departure from how Chinese parents generally impose their own solutions on children -- “my children should just listen to me.” The group leaders validated how this is vastly different from his own upbringing and invited comments from other group members. Mr. Li’s peers suggested that since the children are growing up in the U.S., “they can benefit from the confidence that comes from learning how to express their feelings and solve problems on their own.” By the end of the session, Mr. and Mrs. Li planned to have family meetings on Friday evenings to help Xian get more involved in the family.

Outcomes and Prognosis

By the end of the 14 weeks of group parent training, Mr and Mrs. Li reported that the family was now eating together at the dinner table, Cindy’s tantrums were now infrequent, and Xian was again helping to pick Cindy up from school. Data from the Child Behavior Checklist completed by Mrs. Liu indicate that Cindy had no clinical elevations on externalizing behavior problems at either pre- or post-treatment. However, Cindy dropped from the 90^th percentile in internalizing problems at pre-treatment to the 42^nd percentile at the conclusion of treatment.

Clinical Practices and Summary

The application of evidence-based PT with these two immigrant Chinese families illustrates the feasibility of disseminating it in ways that anticipated and overcome potential cultural barriers. Sensitively attending to treatment-related attitudes and mistrust are particularly urgent for families mandated to treatment by external agencies, such as CPS. Both cases demonstrate the importance of group process, therapist empathy, and cultural knowledge in enhancing engagement. The second case also demonstrates the value of augmenting PT with ancillary skills training to increase its relevance and potency for families dealing with acculturation stress and bicultural family transitions.

In both cases, fidelity to evidence-based PT is high. PT strategies that aroused cultural concerns were never omitted or modified; instead, such concerns were actively explored and integrated in the framing and implementation of skills training. Growing evidence suggests the transportability of evidence-based PT treatments with Chinese-origin families. Data from these cases also suggest that PT can be applied to modify discipline practices among Chinese American parents with children across a wide age range who display externalizing as well as internalizing problems.