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Parent Training With High-Risk Immigrant Chinese Families:A Pilot Group Randomized Trial Yielding Practice-Based Evidence

Anna S. LauJoey J. Fung

Lorinda Y. HoLisa L. Liu

University of California, Los Angeles

Omar G. GudiñoNew York University School of Medicine

We studied the efficacy and implementation outcomes of aculturally responsive parent training (PT) program. Fifty-four Chinese American parents participated in a wait-listcontrolled group randomized trial (32 immediate treatment,22 delayed treatment) of a 14-week intervention designed toaddress the needs of high-risk immigrant families. Parentswere eligible for intervention if they were Chinese-speakingimmigrants referred from schools, community clinics, orchild protective services with concerns about parenting orchild behavior problems. Retention and engagement werehigh with 83% of families attending 10 or more sessions.Results revealed that the treatment was efficacious inreducing negative discipline, increasing positive parenting,and decreasing child externalizing and internalizing pro-

blems. Treatment effects were larger among families withhigher levels of baseline behavior problems and lower levelsof parenting stress. Further augmentation of PT to addressimmigrant parent stress may be warranted. Qualitativeimpressions from group leaders suggested that slower pacingand increased rehearsal of skills may improve efficacy forimmigrant parents unfamiliar with skills introduced in PT.

EVIDENCE FOR THE EFFICACY of parent training (PT)for reducing child conduct problems is rivaled byfew evidence-based treatments (Eyberg, Nelson, &Boggs, 2008; Serketich & Dumas, 1996). Recentdata suggests PT can be efficacious in the reductionof child internalizing as well as externalizingproblems (DeGarmo, Patterson, & Forgatch,2004; Webster-Stratton & Herman, 2008). How-ever, examinations of the moderators of PT effectshave at times revealed that economically disadvan-taged, immigrant, and/or ethnic minority familieshave poorer outcomes, most often in terms of lowerengagement and recruitment (Cunningham et al.,2000; Holden, Lavigne, & Cameron, 1990; Reid,Webster-Stratton, & Beauchaine, 2001) with morescattered evidence of attenuated treatment gains(Caughy, Miller, Genevro, Huang, & Nautiyal,2003; Lundahl, Risser, & Lovejoy, 2006). Theability to systematically investigate racial disparitiesin PT effects, however, has been limited by themeager controlled trial research conducted with

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Behavior Therapy 42 (2011) 413–426www.elsevier.com/locate/bt

The authors are indebted to the families who took part in thisintervention study and to our many community partners whofacilitated the project, including the Chinatown Service Center, theGarvey and Alhambra Unified School Districts, and the AsianPacific Project of the Los Angeles Department of Children andFamily Services. We are grateful to Vanda Yung, Ruth Leong, andJoey Orr for their excellent work as group leaders and to CarolynWebster-Stratton for her guidance and consultation. This researchwas funded by a grant from the National Institute of Mental Health(K01 MH066864), with additional support from the UCLA AsianAmerican Studies Center.

Correspondence to Anna S. Lau, Ph.D., UCLA, Dept. ofPsychology, Box 951563, Los Angeles, CA 90095-1563; e-mail:[email protected]/11/413–426/$1.00/0© 2011 Association for Behavioral and Cognitive Therapies. Published byElsevier Ltd. All rights reserved.


culturally diverse samples (McCart, Priester,Davies, & Azen, 2006).Discourse on the application of PT with ethnic

minority families has enumerated potential culturalbarriers to engagement among parents whose ownsocialization experiences fall outside middle-classEuropean American heritage (e.g., Forehand &Kotchick, 1996; Lau, 2006; McCabe et al., 2005).Given that parent–child relations and disciplinepractices are the proximal targets of change, manyhave cautioned that cultural barriers may threatenthe generalizability of PT. Wide cultural variationin parenting practices and values across ethnicgroups may influence receptivity to proscribedchanges in parent–child interaction patterns, per-haps accounting for increased attrition (e.g., Kazdin& Whitley, 2003) or lowered participation (e.g.,Orrell-Valente, Pinderhughes, Valente, & Laird,1999) among ethnic minorities. As such, PTinterventions targeting ethnic minority familieshave been enhanced by attending to culturalbarriers to engagement (e.g., Carpentier et al.,2007; Matos, Bauermeister, & Bernal, 2009;McCabe & Yeh, 2009). PT that leverages thera-peutic group processes to address cultural andfamilial barriers to the uptake of novel parentingskills have achieved parity in clinical outcomes andsatisfaction across ethnic groups (Reid et al., 2001).In addition, interventionists targeting diverse

families have tailored PT content to addressecological risk and protective factors associatedwith child behavior problems and parenting com-petence in ethnic minority families (Coard,Wallace,Stevenson,&Brotman, 2004; Kumpfer, Pinyuchon,Teixeira de Melo, & Whiteside, 2008; Martinez &Eddy, 2005). As with other efforts to augment PT,these adaptations address ancillary family stressorsthat can heighten child vulnerability and interferewith parent skill acquisition (Miller & Prinz, 1990).These culturally adapted PT protocols haveaddressed risk processes such as acculturation stressand experiences of discrimination (Lau, 2006).Asian American families have been notably

underrepresented in published trials of PT andmost other evidence-based treatments (Huey &Polo, 2008). Although trials of Chinese parents inHong Kong indicate that PT is efficacious in thetreatment of child conduct problems (Ho et al.,1999; Leung, Sanders, Leung, Mak, & Lau, 2003),efficacy research has not included Chinese immi-grants, who represent the second largest immigrantgroup in the United States. In the current study, weused mixed methods to examine PT outcomes inthis target group and to report therapist-observedbarriers in PT implementation. This study providesa valuable window on cultural processes in PT for

two reasons. First, evaluation of PT with Chineseimmigrants may shed new light on cultural barriersto ethnic minority family engagement. Second,applications of PT with Chinese Americans can beinformed by research on contextual stressors facingimmigrant families.

engagement in pt among chineseparents

Clinical observations suggest notable cultural dis-tance between skills typically proscribed in PT andvalues emphasizing parental control often ascribedto Chinese origin parents (Chao & Tseng, 2002).For example, Lieh-Mak, Lee, and Luk (1984)reported that because of a cultural priority toavoid losing face and the need for constantcorrection of improper behavior, Hong KongChinese parents objected to ignoring misbehaviorbased on principles of differential reinforcement.Parents objected to tangible rewards for compliancebecause of Confucian edicts that child compliance isa key filial obligation, not a contractual arrange-ment. Likewise, other interventionists have notedthat praise is problematic for Chinese parents owingto beliefs that praising children for accomplish-ments will result in lack of humility, complacence,and decreased effort to do better (Crisante & Ng,2003; Ho et al., 1999). Among Chinese-Americanimmigrants, low levels of acculturation and en-dorsement of traditional Chinese child-rearingvalues concerning strict discipline and shaming areassociated with lower perceived acceptability of PT(Ho, McCabe, Yeh, & Lau, in review).

augmenting pt content to addressimmigrant family stressors

The PT program evaluated in the current trialconsidered culturally relevant risk factors forineffective parental discipline in immigrant Chinesefamilies. For immigrant families, stress associatedwith immigration, acculturation, and minoritystatus can contribute to ineffective parenting.Within immigrant families, adjustment difficultiescan arise as children acculturate more rapidly thantheir parents resulting in estrangement, conflict, andparental aggression (Farver, Narang, & Bhadha,2002; Lee, Choe, Kim, & Ngo, 2000; Park, 2001).In a previous study, we reported that immigrantChinese parents who value traditional forms ofhierarchical parental control are more likely to usephysical punishment in response to acculturationconflicts (Lau, 2010). Viewing an acculturatingchild's bids for autonomy through a traditionallens favoring parental authority may elicit negativeaffect and antagonistic attributions, fueling

414 lau et al .


punitive parenting. Another salient source of stressin immigrant Chinese families relates to demandsfor school achievement. Chinese immigrants oftenmigrate to invest in their children's schooling,sacrificing the security of extended family, com-munity, and homeland (Fuligni & Yoshikawa,2004). Indeed, children's problems in school are astrong predictor of reliance on physical disciplineamong Chinese immigrant families (Lau, 2010).These considerations guided the current effort toimplement PT with high-risk Chinese immigrantfamilies.We evaluated a version of the Incredible Years

parenting program (IY; Webster-Stratton & Reid,2003) that targeted risk factors associated withphysical discipline in immigrant Chinese families inour previous work. Our aims were to establishcommunity partnerships to effectively recruit andretain immigrant Chinese families in PT and toexamine the feasibility and outcomes of a culturallyinformed PT program. We examined the instru-mental outcomes of positive parenting, harshdiscipline, and parenting stress as well as theultimate outcomes of child externalizing and inter-nalizing behavior problems in a sample of high-riskChinese immigrant families. In addition, we exam-ined whether changes in parenting accounted forgains in child behavior problems. Furthermore, weexplored potential moderators of outcomes includ-ing acculturation, and baseline levels of parentingstress and behavior problem severity. Finally, wepresented qualitative impressions of implementa-tion processes based on exit interviews with groupleaders. These observations were a key facet of ourevaluation to inform further refinements to theintervention protocol in ways not afforded by thequantitative outcome data. Mixed methodsapproaches have considerable utility in formativeintervention research with culturally diverse groupswithin an iterative approach to adaptation (Kumpferet al., 2008; Nastasi et al., 2007).

Methodparticipants

Participants included 54 Chinese American parents(89.7% mothers) and their children (61.7% boys)between the ages of 5 and 12 years (M=8.4,SD=2.0) who were referred for PT for concernsabout parental discipline or child behavior pro-blems. Parents were on average 41.8 years of age(SD=7.2), and their length of residence in theUnited States ranged from 2 months to 12 years(M=29.4, SD=42.1). Most parents reported hav-ing attained a high school education or less(67.5%). The majority of the families reported

annual family incomes below $50,000 (71.4%). Inthis pilot trial, eligible parents self-identified asbeing of Chinese descent, immigrated to the UnitedStates after the age of 18, spoke Mandarin orCantonese fluently, and identified difficulties witheither parenting or child behavior problems. Therewas no diagnostic inclusion criterion; parentsneeded only to be referred by a community partnerand self-identify a need for PT.We conducted community outreach facilitated by

local agencies and schools to identify high-riskfamilies. Home–school coordinators, child protec-tive services social workers, and community clin-icians provided referrals to project research staff. Asa result, 117 parents were referred across threewaves of outreach from community mental healthclinics (n=35), child protective services (n=21), andlocal public elementary schools (n=61). Of thesereferrals, 35 (29.9%) declined participation, 24(20.5%) could not be reached, and 4 (3.4%) wereineligible. The 54 families enrolled were clusteredinto groups by the project coordinator based onlanguage (Cantonese andMandarin) and geographicproximity to treatment sites. Approximately half thesample (48.1%) had elevated internalizing orexternalizing problems (T score N65) by parentreport on the Child Behavior Checklist (CBCL;Achenbach & Rescorla, 2001), with 40.8% ofchildren having elevated internalizing problems and38.8% having elevated externalizing problems.

FIGURE 1 Participant flow chart.

415parent tra in ing with immigrant ch ine s e fam i l i e s


Figure 1 shows enrollment and retention offamilies in the trial. Baseline assessments could notbe completed prior to the start of the interventiongroups for two of the immediate-treatment and twoof the delayed-condition families. Three familiesdropped out of the immediate-treatment condition,whereas six dropped out of the delayed-treatmentcondition. This yielded a treatment retention rate of83.3%. Posttreatment/postwait-list data were thuscollected from 29 families in the immediate condi-tion and 16 families in the delayed condition. Usingintent-to-treat conventions, our main end-pointanalyses included all families for whom baselinedata was obtained (n=50).

procedure

Within each of the three waves of outreach, parentswere assigned to one of two groups based on theirarea of residence and preferred language asdescribed above. With one exception, the cohortsshowed no significant differences on family demo-graphics or baseline problems. The second cohortwas lower on parental acculturation compared tothe first cohort but was not significantly differentfrom the third cohort. Groups were randomized bycoin toss (by the first author) to receive eitherimmediate (n=32) or delayed treatment (n=22).The project coordinator then informed families oftheir group start date. Six groups, ranging in sizefrom 5 to 10 parents, were conducted at communityclinic or school sites. Group leaders included threemaster's-level clinicians assisted by coleaders whowere doctoral students in clinical psychology. Allgroup leaders were bicultural, bilingual ChineseAmericans who received group-leader training in a3-day workshop on the Incredible Years BASICParenting Program and subsequently receivedweekly supervision from the first author. Treatmentgroups were conducted from October 2006through June 2008.

intervention

The treatment implemented was the IY programincluding material from the IY BASIC School-AgedProgram 9 (Promoting Positive Behavior), 10(Reducing Inappropriate Behavior), and 10 (Sup-porting Your Child's Education), as well as the IYADVANCE Program 5 (How to CommunicateEffectively With Children and Adults) and 7(Problem Solving with Children). The protocolincluded 14 sessions, 9 covering the basic skills ofchild-directed play, praise, tangible rewards, effec-tive commands, ignoring misbehavior, time-out,and logical consequences. More specialized contentwas encompassed in the remaining five sessions.Cognitive restructuring was introduced to help

parents to control upsetting thoughts about chil-dren's bids for autonomy and school-relatedproblems. Parents were taught to identify blamingattributions that lead to punitive discipline orhelpless thoughts that lead to inconsistent disciplineand replace them with nonblaming, self-efficaciousthoughts that mobilize effective behavior manage-ment. Communication training introduced skills toaddress recurrent conflicts common in immigrantfamilies through active listening, problem-solvingsteps, and structured family meetings. To preventpunitive responses to school problems, strategieswere introduced for increasing positive proactiveparental involvement in children's schooling.Attending to the needs of parents with limitedEnglish, parentswere guided inways to show interestin their child's schoolwork, structure a homeworkroutine, limit screen time, and coach persistence inthe face of difficulties. In-depth case examples arereported in Lau, Fung, and Yung (2010).By introducing skills in a collaborative rather

than didactic manner, IY incorporates features topromote engagement in PT (Webster-Stratton,2009). When each skill is introduced, parentsdiscuss the benefits and barriers to using the skillwhile the group leader actively elicits parents' viewson potential cultural and practical barriers. Thegroup highlights the benefits of the technique forthe achievement of parents' stated goals. Videosshow parents using each strategy and the groupleader facilitates a discussion in which the parentsconstruct the principles underlying effective use ofthe strategy. The group leader manual orientstherapists to common concerns about each PTskill (e.g., concerns that praise will “spoil” children,worries that time-out is not punitive enough).Rehearsal is emphasized, with role-play, and closemonitoring of homework assignments. As recom-mended, we provided family meals before groupand child care during group to permit workingfamilies to attend without the added stress ofpreparing meals and supervising children's home-work on busy weeknights.A random sample of one third of the PT session

videos were rated for fidelity by trained observerswho were bilingual doctoral students in clinicalpsychology who also served as group coleaders.Observers did not rate videos from their owngroups. The IY Parent Group Leader ProcessRating scale was used to rate elements of collabo-rative teaching, behavioral rehearsal support (e.g.facilitating role plays), and group process skills.These data suggested that the group leadersadhered well to manualized therapy process, withmean ratings of 4.31 to 4.79 out of 5 across thetherapy process elements. As another measure of

416 lau et al .


fidelity, group leaders completed detailed sessionchecklists to ensure that the requisite interventioncontent was delivered. On average, 79.6% ofvideotaped vignettes were shown and discussed,74.5% of assigned role plays were completed, and82.0% of homework guidance and monitoringactivities were completed. Together these datasuggested that the therapy process was adherent,but some problems with fidelity arose with com-pletion of the required session content.

assessment

Families within the immediate-treatment groupcompleted assessments at pretreatment, posttreat-ment, and at 6-month follow-up (total of threeassessments). Families in the delayed-treatmentgroup completed an additional baseline assessmentat the conclusion of treatment for the yokedimmediate group (total of four assessments). Thissecond baseline assessment served as the compar-ison point for the postassessment. Assessmentswere conducted using measures previously estab-lished with Chinese samples. We administeredprevious Chinese translations of measures or newtranslations produced through a process of trans-lation, back-translation, and reconciliation for con-ceptual equivalence by a team of native Cantoneseand Mandarin speakers. Assessments were con-ducted in family homes, or at clinic sites dependingon family preferences. Bilingual research assistantsblind to condition and time point collected datafrom parents.

measures

DemographicsParents completed a demographic questionnaire onimmigration history, socioeconomic status vari-ables, and family composition. To report income,parents selected the category reflecting their annualgross family income 1 (less than $4,999) to 10(more than $100,000). For educational attainment,parents indicated whether they had completed 1(less than high school), 2 (high school or equiva-lent), 3 (college education), or 4 (postgraduatetraining). Parents also reported their length ofresidence in the United States (reports wereconverted into number of months).

Parent AcculturationThe Stephenson Multigroup Acculturation Scale(SMAS; Stephenson, 2000) was used to measureparent acculturation toward the dominant Ameri-can culture and the heritage Chinese culture. TheSMAS consists of 32 items rated on a 4-point scalefrom 1 (false) to 4 (true). Items load onto twofactors measuring ethnic society immersion (encul-

turation) and dominant society immersion (accul-turation) on a number of domains including thefollowing: language use, social interaction, food,and media (e.g., “I eat traditional foods from mynative culture” or “I am informed about currentaffairs in the United States”). The validity of theSMAS is supported by expected convergence ofscale scores with generational status among ethnicminority adults in the United States (Stephenson,2000). The SMAS demonstrated good internalconsistency in the present sample (α= .86 foracculturation, α=.88 for enculturation).

Child Behavior ProblemsChild behavior problems were assessed usingparent reports on the CBCL (Achenbach &Rescorla, 2001). On the CBCL, parents arepresented with a list of 118 behavioral andemotional problems and indicate whether eachitem is 0 (not true), 1 (somewhat or sometimestrue), or 2 (true or often true) for their child basedon the preceding 6 months. The measure yieldsbroadband factor scores for internalizing (anxious/depressed, withdrawn, and somatic complaints)and externalizing (aggressive and rule-breakingbehavior) problems. Published internal consistencyestimates of the Chinese version of the CBCL weresatisfactory, with alphas of .80 and .83 for theinternalizing and externalizing subscales, respec-tively (Yang, Soong, Chiang, & Chen, 2000). Test–retest reliability estimates also fell in the .80 rangeacross the CBCL subscales when used in a Chinesesample (Leung et al., 2006).

Parenting StressThe Parenting Stress Index–Short Form (PSI-SF;Abidin, 1995) is a 36-item scale for measuringparental distress. We used the Chinese version ofthe PSI-SF, which was validated in research onmaltreating samples of parents in Hong Kong(Chan, 1994; Tam, Chan, & Wong, 1994). In thecurrent study, the total score was utilized toexamine levels of parenting stress as an outcomemeasure. Internal consistency in the present samplewas good (α=.89).

Parenting BehaviorThe Alabama Parenting Questionnaire (APQ;Shelton, Frick, & Wootten, 1996) is a 42-itemscale that measures parenting practices acrossdifferent domains utilizing a 5-point scale: never,almost never, sometimes, often, and always. In thecurrent study, we used the 16-item positiveinvolvement (e.g., “I drive my child to specialactivities”) and the 7-item negative discipline (e.g.,“I spank my child with my hand”) subscales.



Published internal consistency estimates of the APQin a mixed sample of European and East Asianparents indicate high test–retest reliability (r=.85)and moderate internal consistency (α=.67). In thecurrent sample, the positive involvement (α=.86)and negative discipline (α=.77) subscales had goodinternal consistency.

Therapist Focus GroupFollowing the completion of the groups, weconvened a meeting of the six master's-levelChinese American group leaders to gather theirimpressions of the implementation. Three groupleaders were staff clinicians at our communitypartner agency, one was a social worker, whereasthe other two held degrees in marriage and familytherapy. Three additional group leaders weredoctoral students in clinical psychology whowere paired to colead groups with agency staff.Group leaders were asked about what contributed

to the success of the program, what barriers toimplementation were perceived, and what theybelieve led to improved outcomes for this popu-lation.

Resultsrandomization check

Table 1 displays means and standard deviations ofdemographic variables, measures of acculturation,child behavior problems, and parenting at baselinefor the immediate- and delayed-treatment groups.Based on independent sample t tests, there were nosignificant differences in child age, parental educa-tion, family income, or parental acculturation toAmerican culture between the groups. Similarly, nosignificant group differences emerged for internal-izing problems, externalizing problems, positiveinvolvement, negative discipline, or parenting stressat pretreatment.

Table 1Baseline Characteristics by Intervention Condition

Immediate Treatment(N=32)

Delayed Treatment(N=22)

t(52)

M SD M SD

SociodemographicsChild age 8.71 2.23 8.08 1.62 1.13Mother's education level 2.29 .56 2.00 .47 1.93⁎Father's education level 2.38 .80 2.32 .75 .25Family income 4.67 2.92 4.58 2.50 – .15Parent acculturation 2.30 .52 2.18 .43 .88

Child behavior problemsInternalizing CBCL 54.40 9.71 56.82 10.81 – .79Externalizing CBCL 54.27 10.43 59.29 11.17 –1.55

ParentingAPQ positive involvement 59.45 8.03 58.89 8.29 – .35APQ negative discipline 14.28 3.65 15.56 4.06 –1.34PSI total stress 95.10 13.16 101.89 11.81 –1.79

Note. CBCL=Child Behavior Checklist; APQ=Alabama Parenting Questionnaire; PSI=Parenting Stress Index. ⁎pb .10.

Table 2Summary of Intent-to-Treat Analyses of Primary Treatment Outcomes

Time 1 Time 2 ANCOVA PosttreatmentESa

ImmediateTreatment

DelayedTreatment

ImmediateTreatment

DelayedTreatment

F (1, 49) ηp2 δ

M SD M SD M SD M SD

Child OutcomesInternalizing Problems 54.40 (9.71) 56.82 (10.81) 50.90 (9.36) 57.24 (8.77) 6.12⁎ .12 – .51Externalizing Problems 54.27 (10.43) 59.29 (11.17) 53.30 (8.76) 60.59 (9.82) 5.39⁎ .11 – .40

Parent OutcomesPositive Involvement 59.45 (8.03) 58.89 (8.29) 61.81 (8.12) 56.19 (7.65) 9.29⁎⁎ .17 .49Negative Discipline 14.28 (3.65) 15.56 (4.06) 12.48 (3.15) 15.86 (3.92) 6.56⁎ .12 – .71Parenting Stress 95.10 (13.16) 101.89 (11.81) 91.55 (16.79) 97.72 (13.06) .005 .00 .07

Note. aCohen's δ effect size based on difference between posttreatment means adjusted for pretreatment scores. ⁎ pb .05, ⁎⁎ pb .01.

418 lau et al .


attrition analyses

There was an 83.3% overall retention rate in theintervention study and 43 of 54 (79.6%) parentsattended at least 10 out of 14 sessions. The researchteam was able to obtain follow-up data from 45 outof 54 families. We examined possible differencesbetween families who were lost to follow-up (n=9)compared to those who provided data at both pre-and posttreatment (n=45). Based on independentsample t tests, there were no significant differencesbetween groups in terms of child age, parentaleducation, family income, parental acculturation,baseline behavior problem, or parenting.

pre- to posttreatment efficacy

We used ANCOVA analyses to examine the effectof group on posttreatment measures of behaviorproblems, parenting, and parenting stress, control-ling for baseline measures. Here, we report intent-to-treatment analyses, carrying the last observationforward for missing posttreatment observations.Table 2 displays the results indicating that imme-diate treatment was associated with gains inpositive involvement, F(1, 49)=9.29, p=.004, andnegative discipline, F(1, 49)=6.56, p=.014, as wellas parent-reported internalizing, F(1, 49)=6.12,p=.02, and externalizing child behavior problems,F(1, 49)=5.39, p=.02. ANCOVA-based effect sizesassociated with these results were large (rangingfrom ηρ

2= .11 for externalizing problems to ηρ2 = .17

for positive involvement). However, no significantgroup effect was observed at posttreatment forparenting stress when controlling for baselinelevels. Effect sizes based on posttreatment meansafter adjusting for pretreatment differences betweengroups suggested effects in the medium to largerange for parenting (δ=.49 for positive involve-ment, δ=–.71 for negative discipline), with anegligible effect on parenting stress (δ=.07). Medi-um effect sizes were observed for the primaryoutcomes (δ=–.51 for internalizing problems,δ=–.40 for externalizing problems).

mediation analysis

We examined whether improvements in the inter-mediate outcome of parenting quality for families inthe immediate-treatment group explained childbehavior outcomes. We created change scores forpositive involvement and negative discipline frompre- to posttreatment using standardized residualsto determine whether these changes mediatedtreatment effects on internalizing and externalizingproblems. We did not examine changes in parentingstress as a mediator because parenting stress did notimprove as a function of treatment in the efficacyanalyses described above. We employed a series of

multiple regression analyses to examine the condi-tions for testing mediation. First, treatment condi-tion predicted posttreatment internalizing (β=–.24,pb .05) and externalizing problems (β= –.19,pb .05) controlling for baseline levels. Second,treatment condition was significantly associatedwith changes in positive involvement (β= .25,pb .01) and negative discipline (β=–.27, pb .05).Third, the putative mediator of changes in negativediscipline was related to changes in externalizingproblems (β=.22, pb .05), but not to changes ininternalizing problems (β=.11, p=.31). Contraryto predictions, changes in positive involvementwere not significantly associated with improve-ments in internalizing (β=–.12, p=.25) or exter-nalizing problems (β=–.01, p=.87). Therefore, thefinal step of the mediation analysis utilizinghierarchical regression examined negative disci-pline as a mediator of the effect of treatment onexternalizing problems. As displayed in Table 3,when change in negative discipline was added to theequation, it independently predicted variance inposttreatment externalizing problems after control-ling for baseline levels (β=.19, pb .05) and treat-ment condition status no longer predictedexternalizing outcomes, suggesting mediation.The Sobel test indicated that the effect of theintervention on externalizing behavior problemswas significantly mediated by changes in negativediscipline (z=1.92, pb .05).

moderator and follow-up analyses

To explore treatment effects over 6-month follow-up as well as potential variability in treatmenteffects, we pooled data from the immediate- anddelayed-treatment groups from baseline to post-treatment to 6-month follow-up. We examinedbaseline behavior problem severity (above orbelow the cutoff of T=65 on total behaviorproblems), parenting stress (above or below themedian on the PSI-SF), and parental acculturation

Table 3Regression Analyses of Negative Discipline as a Mediator ofIntervention Effects on Externalizing Behavior Problems

B SE β

Step 1Time 1 externalizing problems .74 .07 .81⁎⁎Treatment condition –3.33 1.61 – .17⁎

Step 2Time 1 externalizing problems .73 .07 .79⁎⁎Treatment condition –2.12 1.60 – .11Negative discipline 1.88 .77 .19⁎

Sobel z=1.92⁎

Note. ⁎ pb .05, ⁎⁎ pb .01.



(above or below the median on SMAS accultura-tion) as potential moderators of intervention effectson child behavior problems and parenting out-

comes.We specifiedmixed-effectsmodelswith threerepeated measures for each outcome, examining theeffects of time, each moderator variable, and the

Table 4Pretreatment, Posttreatment, and Follow-Up Outcomes in the Full Sample With Moderator Analyses

PreM (SD)

PostM (SD)

Follow-UpM (SD)

F(1, 80)(Time)

F(2, 80)(CBCL⁎T)

F(2, 80)(PSI⁎T)

F(2, 80)(Acculturation⁎T)

Child OutcomesInternalizing Problems 54.87a (9.45) 50.62b (9.90) 47.57c (10.32) 18.12⁎⁎ 5.22⁎⁎ 3.65⁎ .06Externalizing Problems 56.13a (10.61) 53.70b (9.79) 50.43c (9.66) 27.69⁎⁎ 19.37⁎⁎ 1.33 .06

Parent OutcomesPositive Involvement 59.35 (8.69) 61.85 (9.25) 60.91 (8.90) 1.51 1.22 1.04 .55Negative Discipline 14.19a (3.93) 12.73b (3.30) 12.47b (3.30) 7.57⁎⁎ .59 4.29⁎ .40Parenting Stress 97.59a (15.02) 91.79b (16.23) 88.62b (16.76) 5.60⁎⁎ .51 .85 .06

Note. Means with different superscripts denote significantly different means. ⁎pb .05, ⁎⁎pb .01.

High parenting stress

High parenting stress

Low parenting stress

Low parenting stress

A B

C D

70.00

65.00

60.00

55.00

50.00

45.00

60.00 2.20

2.00

1.80

1.60

55.00

50.00

45.00

40.00

1 2 3Time

1 2 3Time

1 2 3

Time

1 2 3Time

Inte

rnal

izin

g P

rob

lem

sIn

tern

aliz

ing

Pro

ble

ms

Neg

ativ

e d

ecip

line

70.00

65.00

60.00

55.00

50.00

45.00

Ext

ern

aliz

ing

Pro

ble

ms

CBCL T ≥ 65

CBCL T ≥ 65

CBCL T ≥ 65

CBCL T < 65

FIGURE 2 Moderators of outcomes over time. A and B. Families with elevated total child behavior problemscores at baseline show more improvement on child internalizing and externalizing problems. C. Families withhigh levels of parenting stress at baseline show fewer treatment gains in child internalizing problems. D. Familieswith high levels of parenting stress at baseline show fewer treatment gains in negative discipline, though outcomesappear to converge at follow-up.

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interactions between the moderator variables andtime. Mixed-effects models are preferred overtraditional repeated measures ANOVA owing togreater flexibility in modeling time effects andretention of all observations, preventing data lossincurred with listwise deletion (Gueorguieva &Krystal, 2004).As displayed in Table 4, in the pooled sample

there were significant effects of time on internalizingand externalizing behavior problems, F(1, 60)=18.12, pb .01 and F(1, 60)=27.69, pb .01, respec-tively, parenting stress, F(1, 60)=5.60, pb .01, andnegative discipline, F(1, 60)=7.57, pb .01, but noton positive parent involvement. We also examinedpost hoc contrasts to determine whether treatmentgains from pre- to posttreatment were sustained at6-month follow-up. For the primary outcomes,improvements in internalizing and externalizingproblems from pre- to posttreatment were enhancedat follow-up, with 6-month follow-up means beingsignificantly lower than posttreatment means. Forthe intermediate parenting outcomes of parentingstress and negative discipline, treatment gains weresustained with no significant differences betweenposttreatment and 6-month follow-up means.There was a significant interaction effect between

time and total behavior problems at baseline forinternalizing problems, F(2, 80)=5.22, pb .01, andexternalizing problems, F(2, 80)=19.37, pb .01.Post hoc subgroup regression analyses were con-ducted to clarify the nature of this interaction. InFigures 2A and 2B, we plotted simple intercepts andslopes for emotional and behavior problem out-comes as a function of baseline problem levels(above and below clinical cutoff of T=65). Figure2A shows a significant main effect of time oninternalizing problems for children scoring abovethe clinical cutoff for total behavior problems atbaseline, F(1, 32)=17.81, pb .001, but this rela-tionship was not significant for children scoringbelow the cutoff, F(1, 107)=4.21, ns. Similarly,Figure 2B shows a main effect of time on childexternalizing behavior problems for children scor-ing above the clinical cutoff at baseline, F(1, 32)=40.65, pb .001, but not for those scoring below theclinical cutoff, F(1, 107)= .70, ns.There was also a significant interaction between

time and parenting stress on internalizing out-comes, F(2, 80)=4.29, pb .05. Post hoc analysesdepicted in Figure 2C showed a significant maineffect of time on internalizing problems for parentsreporting low parenting stress at baseline, F(1, 76)=13.57, pb .001, but this relationship was notsignificant for parents reporting high parenting stressat baseline, F(1, 63)=1.43, ns. Lastly, we found asignificant interaction effect of time and parenting

stress on negative discipline, F(2, 80)=3.65, pb .05.Figure 2D shows a significant main effect of timeon negative discipline for parents reporting lowparenting stress (below the median) at baseline,F(1, 80)=5.37, pb .05, but this relationship was notsignificant for parents reporting high parenting stressat baseline, F(1, 47)=2.26, ns.There were no other significant interactions

between putative moderator variables and time onthe outcomes of interest. Of note, parents of highand low acculturation levels did not appear to havedifferent outcome trajectories over time. However,there was a significant main effect of acculturationon externalizing behavior problems, F(1, 58)=4.24,pb .05, and a marginal effect of acculturation oninternalizing behaviors, F(1, 57)=3.38, p=.071. As

FIGURE 3 A and B. Families with less acculturated parents havehigher reported internalizing and externalizing problems acrosstime points, but acculturation did not moderate outcomes.



shown in Figures 3A and 3B, parents who were lessacculturated (below the median) consistentlyreported more behavior problems from pretreat-ment through follow-up as compared to those whowere more acculturated.

practice-based evidence: therapistperspectives on process and outcomes

PT Intervention ContentGroup leaders shared their impressions about theintervention content that was most valuable for theimmigrant Chinese families they served. Groupleaders nominated the sessions covering child-directed play, praise, ignoring misbehavior, andcontrolling upsetting thoughts as the critical contentfor achieving outcomes. They noted that lessonsfocused on increasing positive attention were vitalfor parents, but they involved “brand new skills forour families.”One leader remarked, “Culturally weare produced to be didactic. Everything, play, orwhatever, has to have an educational purposebehind it.” Thus, child-directed play was difficultto learn as parents were inclined to instruct, guide,and correct their children in activities. In contrast,group leaders felt praise was not a new concept toChinese immigrant parents but the techniques werenonetheless difficult to implement: “The parentsknow in theory that praise is helpful, but when theyactually praised, the words, the statements that theyused, were not necessarily praise. It was alwaysweighted with criticism.” These lessons requiredextended rehearsal for making change and sustain-ing gains. One leader described parents backsliding,“We found out towards the end of the group theparents forgot all the beginning basic skills, likepraising, spending special time, those skills. Forgot!Initially, when we introduced [the skills] to themthey were able to do it right, with homework. Andthen, towards the end, it was all gone.” These basicskills are then the prerequisites for later lessons onproblem solving and communication when immi-grant parents “are still trying to get hold of thefoundation skills [and are] not yet ready for themore advanced skills.”

Effective Therapy ProcessNext, group leaders commented on the therapeuticprocess elements that led to change. Group leadersdid encounter misgivings about PT among Chineseparents. For example, two fathers mandated totreatment by child protective services “did notreally buy into time-out. They didn't think it was abig enough punishment for bad behavior”; theyvalued more punitive discipline. Group leadersreported that ignoring was sometimes seen asunacceptable: “They are cultured to reprimand,

you know, and criticize and yell and direct. Whenyou talk about ignoring the kid, they think you aregiving them more power.” Such concerns wereelicited in the Benefits and Barriers exerciseincorporated in each session as a means ofcollaborating with parents and cultivating thetherapeutic relationship. Listening with empathyand open discussion of cultural concerns facilitatedbonding between and among the group leaders andthe parents. Working alliance was further achievedby exchanging viewpoints on PT strategies andexploring how each could be used in a way thatworks toward goals while averting unwantedconsequences. For example, parents often felt thatchildren ought not be praised for expected beha-viors: “Listening to parents is simply a must.”Many believed that praise can decrease children'smotivation: “If you praise them, they'll stop tryinghard.” Group leaders validated these concerns andwarned against inappropriate applications of praisethat can indeed promote complacence. Then groupleaders reinforced the importance of specific labeledpraise focused on effort, which can increase thevalued goals of persistence and improvement.Yet, these engagement strategies were not viewed

as sufficient for good outcomes. Group leaders feltthat many PT skills were difficult for traditionalChinese parents to carry out: “Monolingual first-generation parents need more guidance, moresupport, and hands-on practice.” The interventionwas effective to the extent that parents weresupported in extensive practice in role-play andhome activities. Group leaders felt it was necessaryto make homework assignments as customized aspossible: “We came up with specifically what theyshould do for their homework, not just a generalassignment.” For example, instead of askingparents to choose a behavior to praise their childfor each day, the assignment would be individual-ized (e.g., “Mr. Wong, you said you would like topraise Anthony as soon as he sits down to do hishomework before dinner.”) This made the applica-tion of skills concrete and engaged each parent in aclear social contract for the week.Unfortunately, group leaders also felt it was

difficult to provide enough facilitated practice in thecourse of the 14-week protocol: “It seems like wedo not have sufficient time to kind of walk themthrough the practice enough on those particularskills to be reinforced because we have to move onto the next topic.” Despite her belief that rehearsalwas a key mechanism of change, another groupleader admitted honestly, “If we are pressed fortime and setting priorities—get through the curric-ulum or the role-play practice—the role play isoften left off.” When group time was devoted to

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group discussion around cultural barriers to PTskills, role plays were less numerous.

DiscussionThe results of this preliminary trial of anaugmented PT intervention for high-risk immi-grant Chinese families provided initial evidence ofefficacy. Evidence-based PT that attends respon-sively to cultural barriers to engagement and skillspertinent to immigrant families can yield strongtreatment effects in improving parenting and childbehavior problems in immigrant Chinese families.We observed a high level of retention in treatment,with 83% of families completing the 14-weekintervention with most of the drop out observed inthe wait-list period of the delayed-treatmentcondition. Relative to parents in the delayed-treatment condition, parents who received theintervention responded with lower levels ofnegative discipline and increased positive involve-ment practices with their school-age children. Inaddition to these intermediate parenting outcomes,effects were evident in decreased child internaliz-ing and externalizing behavior problems at post-treatment. Effect sizes were in the medium to largerange for child behavior problems depending onthe index at posttreatment, comparable to findingsfrom majority group samples of parents receivingevidence-based PT. Pooling data from acrossconditions, we noted that further reductions inchild behavior problem levels were observed fromposttreatment to 6-month follow-up. Although wedid not have a control condition for the follow-upperiod, these data provide preliminary support forshort-term durability of treatment effects. Furtherstudy is warranted to determine whether PT mayproduce delayed or sleeper effects with immigrantfamilies where gains in parenting may come slowlyand may continue to produce improvements inchild behavior over time (Barrera et al., 2002).This was a heterogeneous high-risk sample

referred for either parenting problems (i.e., suspectedchild maltreatment) or child adjustment difficulties(i.e., school referrals), and there were no diagnosticcriteria for entry into the study. Thus, the trial can beviewed within an indicated prevention approach,with differential treatment response depending onbaseline severity of child behavior problems. Con-sistentwith the literature, intervention efficacy variedby initial status such that the children with elevatedbehavior problems at baseline were the ones thatbenefited most (Lundahl et al., 2006).Results of mediation analyses revealed that

decreases in negative discipline accounted forimprovements in child externalizing problems.

This mirrors the results from an examination ofputative mediators of outcomes of the IY interven-tion, where changes in observed critical and harshparent behaviors explained changes in child exter-nalizing outcomes (Beauchaine, Webster-Stratton,& Reid, 2005). However, treatment-relatedchanges in positive parenting behaviors did notmediate child internalizing or externalizing out-comes. Furthermore, we were unable to identifyparenting mediators that accounted for changes inchild internalizing problems. Given the smallsample size, we had limited power to examinethese mechanisms of action. Additionally, theseanalyses are subject to criticism because wemeasured putative mediators concurrent withposttreatment outcomes (Kazdin & Nock, 2003).The finding that improvements were observed in

both internalizing and externalizing problems isconsistent with recent findings that PT has impactsacross both broad dimensions of child behaviordisturbance. Secondary analyses of data fromcontrolled trials of IY have also revealed clinicallysignificant improvements in child internalizingproblems, with strong effect sizes among childrenwith elevated internalizing symptoms at baseline(Webster-Stratton & Herman, 2008). Althoughoriginally developed to reduce conduct problems,PT targets familial risk factors for child depressionand anxiety, including unpredictable, non-nurturing,and harsh or critical parenting behaviors. Thus, PTmay be promising for remediating a range of childadjustment problems related to family distress. Thismay be especially relevant in the treatment ofchildren in East Asian contexts where culturalsocialization forces may shape the expression ofchild distress toward internalizing manifestationsrather than overt conduct problems (Weisz,McCarty, Eastman, Chaiyasit, & Suwanlert, 1987).Two intermediate outcomes for which efficacy

was not clearly supported were parenting stress andpositive parenting. Pre- to posttreatment efficacyanalyses suggested a treatment effect on positiveparenting, but there was no significant effect of timein the pooled sample analyses of outcomes frompretreatment through follow-up. On average,parents in the sample reported high mean levels ofpositive discipline at baseline and there may havebeen a ceiling effect using this measure. Forparenting stress, intent-to-treat analyses did notreveal an effect of the intervention at posttreatment.This finding is inconsistent with previous indepen-dent evaluations of IY using wait-list controlleddesigns and the same measure of parenting stress(Hutchings et al., 2007). Pooled analyses of theentire sample from pretreatment to follow-up didreveal a significant effect of time on parenting



stress, suggesting decreases in parenting stressobservable at both posttreatment and 6-monthfollow-up. However, we cannot safely attribute thischange to treatment as parenting stress may havedecreased with the passage of time followingreferral.Of additional concern was the finding that the

intervention was least effective in reducing inter-nalizing outcomes among families where parentshad high levels of parenting stress at baseline. Whilesome studies have noted that PT is less effectivewhen parents report greater parenting stress ormore life events (Kazdin, 1995; Webster-Stratton&Hammond, 1990), meta-analytic findings havesuggested that the associations between stress andPT outcomes are small (Reyno & McGrath, 2006).An analysis of outcomes of IY among 514 familiesacross 6 randomized trials did not find baselineparenting stress to moderate externalizing out-comes (Beauchaine et al., 2005). Indeed, parity inoutcomes across levels of initial parenting stress canbe expected when the intervention is successful inreducing this stress by improving child managementstrategies, enhancing parent coping skills, andtargeting distressing parental cognitions. Yet, des-pite the inclusion of augmented interventioncontent to address stress in immigrant parent–child relations, intervention effects on parentingstress were not observed at posttreatment and childinternalizing outcomes were negatively impacted byparenting stress. This suggests that the cognitiverestructuring and communication training providedwere insufficient to produce effects among the mostdistressed immigrant parents in the sample. Thesefindings could be used to inform the continuedadaptation of PT protocols for distressed immi-grant families.Likewise, observations of group leaders about

therapy process and outcomes were valuable ingenerating directions for future implementationefforts. Clinician impressions from an exit focusgroup interview converged with the quantitativefindings on retention, as the group leaders feltsuccessful in engaging immigrant Chinese parentsin PT. Although group leaders did have to attend toparents' cultural concerns about PT practices,group process was effective in building a workingalliance and engaging parents to apply strategies inways that were consistent with their goals. Onbalance, group leaders felt competent in addressingcultural barriers related to the acceptability of PTbut had more concerns about cultural barriers inthe learning of new parenting skills. Once attitudi-nal barriers were addressed, parents appearedamenable to culturally unfamiliar strategies. How-ever, group leaders perceived that it was difficult for

immigrant Chinese parents to become facile withthe skills. Parents' cultural upbringing made strat-egies involving attending and positive reinforce-ment particularly foreign, and hence difficult toattain and maintain.Group leaders reported that slowing the pace of

skill lessons and increasing the dosage of behavioralrehearsal may be a promising adaptation to achievemeaningful and enduring changes in parenting inimmigrant families. This need for additionallearning support was suggested in previous trialsof PT with Chinese origin families. Ho et al. (1999)encountered difficulties in teaching Hong KongChinese parents to praise their children and found itnecessary to bolster their instruction with the use offeedback on videotaped behavior samples as well aslive coaching using a “bug in the ear.” Ho et al.reported that some parents refused to praise, butthose who tried initially used praise in a “mecha-nistic and unemotional manner” thus limiting itseffectiveness. Likewise, Crisante and Ng (2003)report that Chinese Australian parents requiredsubstantial practice of the unfamiliar behaviors ofboth giving and receiving praise so that they betterunderstood the intention to evoke positive affect.Our findings likewise suggest that PT with Chineseparents is successful to the extent that behavioralrehearsal is buttressed. This is, of course, not aculturally specific proscription for enhancing PT,and could be said of parents from across culturalgroups. However, the issue of dosing may be vitalfor immigrant parents, and has generally notentered discussions of how to adapt or enhancetreatment effects for diverse families.Critics have noted that interventions developed

for majority populations are often imbued withEuropean American values and behavioral tradi-tions (e.g., assertiveness in social skills training,praising desired child behavior in PT), renderingthem potentially less acceptable to ethnic minor-ities. As newcomers, immigrant parents may havehad limited exposure to child managementstrategies taught in PT, making them foreignand difficult to emulate. However, beyondattitudinal barriers that promote active resistanceamong immigrant parents, cultural differences inchild rearing may present barriers to skillacquisition that limit the pace of progress towardmastery. Even after therapists surmount attitudi-nal barriers to engagement, the cultural distanceof the target skills may render them less easilyassimilated. Immigrant parents may require ad-ditional support to enact, rehearse, and consol-idate behavior changes.Several limitations of the current study should

also be noted. Given that this was a small pilot trial,

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two concerns arise. First, we had limited power todetect therapeutic effects. Second, estimates of theeffect size have a large standard of error. The sampleincluded mainly low- to middle-income immigrantparents residing in ethnically dense communities.Thus, continued research is needed for increasedconfidence in the generalizability of PT outcomesfor immigrant Chinese families across clinicalsamples, community providers, and contexts. Out-comes were assessed by parent self-report and couldbe subject to social desirability and demand effects.Future trials should include multiple-informant,multimethod assessments of outcome.Notwithstanding these limitations, the current

study provides some insights into the adaptation ofevidence-based PT for immigrant families. Contin-ued research is needed to understand the relativecontributions of augmenting interventions withancillary skills training pertinent to specific culturalgroups versus enhancing dosage of basic behavioralskills training to ensure teaching to mastery in thecontext of culturally responsive and engagingbehavioral interventions. Our findings suggestthat additional skills training to effectively reduceparenting stress in immigrant families may yet benecessary to ensure penetration of effects in themost distressed immigrant families. Secondly, itmay be vital to appropriately dose the interventionto be sensitive to the learning needs of immigrantparents unfamiliar with target practices. Theseconsiderations for treatment adaptation presentchallenges in the context of delivering a time-limitedintervention in a way that also incorporateselements for responsive engagement around famil-ial and cultural concerns. Indeed, therapists in thecurrent study were pressed within the time-limitedprotocol to sensitively attend to parents' culturalconcerns, while also providing sufficient opportu-nities for behavioral rehearsal and full coverage ofthe treatment elements. To inform interventionscience with an increasingly diverse population,future trials should address comparative efficacyquestions. Promising designs could manipulateintervention dosage, and provision of augmentedor adapted content for immigrant families, amongother central intervention parameters, could informhow to enhance care for diverse families.

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