Filial Therapy for Children’s Behavioral and Emotional Problems in Mainland China

TOPIC: Filial therapy as a therapeutic intervention to promote parent–child interaction and improve child’s behavior across culture. PURPOSE: To review the state of the science of filial therapy and explore whether filial therapy would be an effective parenting program in China. SOURCES: Four research articles related to the impact of filial therapy, used with Chinese immigrants, Koreans, and Native Americans, were located in a search of nursing, medical, psychological, and social science literature. CONCLUSIONS: The findings indicated that filial therapy is a culturally sensitive and effective intervention. The overall limitations, some recommendations for future research, and the discussion of efficacy of filial therapy in China were provided. Search Filial studies using the


Overview of Filial Therapy
Filial therapy was developed to help parents become therapeutic agents in dealing with their children's problems by using the naturally existing bond between parent and child. Thus is derived the term filial therapy (Guerney, Guerney, & Andronico, 1966). It is based on the principles of child-centered play therapy. The goals of filial therapy for parents are to (a) help parents understand the vital role of play in their children's development; (b) teach parents how to encourage more open communication with their children; (c) increase positive emotions, trust, and intimacy between parents and children; and (d) empower parents and increase their sense of competency and confidence in their ability to parent their children (Guerney, 1997).
Because filial therapy was derived from childcentered play therapy, it is useful to understand the nature and value of child-centered play therapy. Child-centered play therapy is a combination of play therapy and child-centered theory. Play therapy is based on the fact that play is the fundamental language of Filial Therapy for Children's Behavioral and Emotional Problems in Mainland China children, which provides a means for their communication. Thus, play therapy is designed to fundamentally honor children by entering their world of communication, rather than forcing children to enter the adult world of verbalization (Sweeney & Skurja, 2001). Child-centered theory is based on belief in the innate human capacity of the child to strive toward growth and to be constructively self-directing (Guerney, 1997). Therefore, child-centered play therapy is a dynamic and self-healing process, in which children "play out" their experiences and feelings (Landreth, 2002).

Filial therapy is not directed toward specific behavior problems. It is aimed at improving children's self-esteem and the feelings underlying inappropriate behaviors.
Filial therapy has additional assumptions beyond child-centered play therapy. Children's emotional and behavioral problems are the product of parents' lack of understanding of their children's perspectives or knowing how to exercise reasonable and nonviolent control over their children. In filial therapy, parents are taught how to execute the essentials of the role usually taken by play therapists. It is believed that given that a parent has more emotional significance to the child than does a therapist, the anxiety felt by the child under the influence of negative parental attitudes or practices could be more effectively extinguished through a facilitative parent-child interaction than through play therapy with a professional therapist. In addition, it is also proposed that parents as therapeutic agents are more helpful in reducing guilt and feelings of helplessness that often arise when parents feel obligated to abandon their child's problem to experts for resolution (Guerney et al., 1966;Sweeney & Skurja, 2001).
Filial therapy is not directed toward specific behavior problems. It is aimed at improving children's selfesteem and the feelings underlying inappropriate behaviors. These feelings can be addressed by encouraging the child to play them out in the safe atmosphere of a play session and in the presence of a warm and caring parent.

Review of the Literature
Determining the state of the science of filial therapy was undertaken by searching computerized databases CINAHL, MEDLINE, PsycINFO, SOCIALOGICAL ABSTRACTS, and the Cochrane Library with the index words of "filial therapy," "ethnic," and "parenting training." Manual searching for studies relevant to filial therapy was also used. The criteria for article selection included intervention studies using filial therapy preferably with ethnic groups between 1990 and the present. Four research articles in which filial therapy was implemented in the three ethnic groups of Chinese immigrants, Koreans, and Native Americans were selected to critique and synthesize in this review. These are summarized in Table 1. The intervention model was Landreth's 10-week model.

Landreth's 10-Week Filial Model
The four themes in the 10-week filial model developed by Landreth are (a) recognition and response to child's feelings, (b) empathy with the child, (c) imaginative and child-centered play, and (d) limit setting. The model is carried out in a group setting. Each group meets weekly for a 2-hour training session for 10 consecutive weeks. The training includes didactic instruction, videotape viewing, group discussion, demonstration of play sessions, role play, and required at-home laboratory play sessions. During each training session, parents are given a defined therapeutic role to play for a defined period of time and provided with feedback and supervision by the therapist. During the home play sessions, parents are expected to be empathic, understanding, and accepting, while allowing the child to direct the play. These conditions facilitate both children's expression of emotion and a new perceptual awareness from parents about their children. When children are permitted to express themselves without losing status in the eyes of their parents, the children's anxiety diminishes. If they feel validated and valued, children are able to master difficulties and feelings rather than try to distort and deny them. As these changes occur and the communication gap is bridged, children's frustrations and hostilities diminish (Guerney, Guerney, & Andronico, 1999).

Ten-Week Filial Model with Caucasian Populations
The 10-week filial model has been implemented with different Caucasian populations including parents of children with learning difficulties (Kale & Landreth, 1999), non-offending parents of sexually abused children (Costas & Landreth, 1999), single parents (Bratton & Landreth, 1995), parents of chronically ill children (Tew, Landreth, Joiner, & Solt, 2002), and incarcerated fathers (Landreth & Lobaugh, 1998). The findings in the above studies consistently indicate that filial therapy is an effective intervention for increasing parental acceptance and empathy, and children's adjustment and self-esteem, while decreasing parental stress and child behavioral problems.

Ten-Week Filial Model Across Ethnic Groups
While the majority of the research has been conducted with Caucasian participants, four studies address Chinese immigrants, Koreans, and Native Americans. These four studies are summarized in Table 1. In the next section, elements of these studies will be evaluated.

Evaluation of the Ethnic Groups Studies
Generally, the findings in the four studies are relatively consistent with increasing parental empathy and decreasing children's problems. These results support that filial therapy is an effective intervention for three ethnic groups. Despite these promising results, some important research elements need to be further evaluated.

Subjects and Settings
Treated subjects were not selected randomly. Thus it is unclear whether the provision of treatment is con-founded by other factors such as parental motivation which may moderate the outcome. In addition, gender differences may be more prevalent in non-Western cultures. In this sense, gender issues may need to be considered in these studies. First, the gender of child could affect the effectiveness of filial therapy. Second, whether the parent is a mother or a father may affect the effectiveness of filial therapy. None of the four studies reported whether gender was a variable affecting the effectiveness of treatment.
Settings of these studies were varied. Two were in a church (Chau & Landreth, 1997;Yuen, Landreth, & Baggerly, 2002), one was in a kindergarten ( Jang, 2000), and one was not mentioned (Glover & Landreth, 2000). Despite a variance of settings, this factor seems not to influence the effectiveness of treatment in the four studies.

Study Design
The design of these studies is relatively consistent. They all have a pretest-posttest control group design. One limitation is that there was no follow-up design available in these studies. How to maintain newly acquired parenting skills may be a critical issue for non-Caucasian parents, particularly if there is a perceived conflict with their own cultural background. Therefore, strategies, such as encouraging partner and other family members to attend the training, may be needed to help parents maintain filial therapy techniques. A second limitation is the lack of causalrelationship design to explore the changes between parenting practices and their children's behavior. Thus the causal effect of improved parenting led by filial therapy for children's behavior change cannot be supported strongly in the four studies.
A combination of quantitative and qualitative methods was used in the Korean mothers' study (Jang, 2000). The qualitative component revealed some new findings. For example, Korean mothers expressed that filial therapy improved couple communication, and their relationship with other family members. This

Filial Therapy for Children's Behavioral and Emotional Problems in Mainland China
finding may be very important for the culture in which family hierarchy is emphasized. Alternatively, the verbal expression of emotion and couple intercommunication are not always advocated. Filial therapy seems to orient the family atmosphere in a healthier direction with these families. Therefore, qualitative methods will be conducive to explore the ethnic families' perception of filial therapy and how the process of filial therapy affects their families and cultural values.
Filial therapy seems to orient the family atmosphere in a healthier direction with these families.

Variables and Outcomes Measurement
The strength of these studies is that they all provided a clear definition of filial therapy and its mechanism of enhancing parent-child interaction for the child's problems. However, some limitations are related to the contextual variables of risk factors and outcomes measurement.
Risk factors. The missing risk factors relate to the theoretical rationale for filial therapy. In addition to parenting style and skills, other risk factors can affect parent-child interaction and a child's behavior. These include family risk factors such as parents' depression and marital stress, and school risk factors such as ineffective teachers' management skills and low involvement with parents.
The missing risk factors may contribute to the limitations of the studies. First, the missing family risk factors restrain filial therapy from extending to other parenting skills, such as stress management. Some parents who may not participate in the filial therapy, either because of their own dysfunction or lack of support, may not only need skills at interacting with their children but also management skills for themselves as well. Second, missing school risk factors may restrain a child's improvements brought about by filial therapy from extending beyond the home to the school. In other studies of parent training programs, the findings already revealed that while the majority of children improve their social behavior at home, 30 -50% of the children continue to have significant school problems (Webster-Stratton & Herbert, 1994). Intervening with children's teachers, as well as their parents, would seem to offer far better possibilities of generalizing improved social skills across the home and school settings. For children who continue to have behavior problems at school after filial therapy, teacher training may be an alternative approach.
Outcome measures. The missing family and school risk factors may limit the outcome measures. First, child behavior problems measured in the four studies are only in the home environment. As elaborated in the section on risk factors, child behavior problems occur across a variety of settings such as home, school, or relationships with parents, teachers, or peer groups. In this regard, parents' reports of reduced child behavior problems at home cannot necessarily be generalized to school, teacher, or peer relationships in the studies. Second, among the five outcome instruments used in the studies, only Measurement of Empathy in Adult-Child Interaction scale (MEACI) is an observational scale based on a 20-min videotape. All the other instruments are self-reports. In this regard, the validity of findings might be threatened by parents' and children's desire to answer correctly and provide socially desirable responses.

Standard Protocols
The entire 10-week filial model was applied in all three studies. For the two studies of Chinese immigrants, this model achieved significant effectiveness in terms of an increase in parental empathy and acceptance of their children, and a reduction of parental stress and child behavior problems. The model was shortened from 10 weeks to 4 weeks for the study of Korean mothers because the subjects claimed that they did not have enough time to participate for 10 weeks. How the 4-week modification was made was not reported in the study. Length of time might be a variable that influences the effectiveness, because it was reported that there was no significant increase in parental acceptance and decrease in parental stress.
With regard to the protocol of intervention, two major issues may have affected the integrity of the four studies. First, it was not clearly reported whether there was a treatment manual available for trainers in each session. Second, it was not clearly reported whether the quality of filial therapy training and its implementation were monitored or supervised. Therefore, the integrity of intervention may have been threatened by lack of monitoring and comprehensive training manuals.

Generalizability
Three factors may influence the generalizability of results. First, the lack of contextual risk factors such as school risk factors limits the generalization of the parents' reporting reduced child behavior problems at home to child behavior problems at school. Second, the effect of gender is not clarified in the studies. The majority of parents in the four studies are mothers, in addition to having few fathers in the studies of Chinese immigrants. Thus, the findings of the studies may not be generalized to Korean and Native American fathers. Third, parents in the four studies volunteered to participate in the studies and improve their parenting skills, even when their children are normal. Conversely, taking children to see a therapist is often viewed as shaming of their parenting or family honor in some Asian cultures (Chau & Landreth, 1997;Yuen et al., 2002). To the extent this occurs, a clinical setting may itself be a factor that affects parents' motivation to participate in filial therapy and thereby threaten the generalizablility of the study results to the clinical setting in some Asian cultures.

. . . taking children to see a therapist is often
viewed as shaming of their parenting or family honor in some Asian cultures.

Implications for Future Research
The empirical findings of the four studies substantiate that filial therapy is a culturally sensitive and effective therapy. However, some aspects still need further exploration. Randomized controlled trials with causal relationship and long-term follow-up are required to firmly establish the efficacy of filial therapy for children with behavior problems. Additionally, the effectiveness of filial therapy needs to be compared with other effective parenting interventions, which include play skills and other components of parenting, such as discipline skills in the BASIC Parenting Training by Webster-Stratton and Herbert (1994). It will be very helpful to explore whether the parenting skills acquired in filial therapy are enough to be generalized to other parent-child interactions, such as supporting the child's schoolwork.
Studies with qualitative design could reveal ethnic families' perception of filial therapy and how the process of filial therapy affects their families and culture values. Contextual risk factors need to be embraced in future studies. Inclusion of risk factors related to school will extend outcomes from the parents' perceptions of child behavior problems at home to teachers' perceptions of child behavior problems at school environment. In this regard, filial therapy may be Filial Therapy for Children's Behavioral and Emotional Problems in Mainland China also expanded from parenting training to teacher training.
Effectiveness of filial therapy, play therapy, and a combination of a filial therapy and play therapy, in which a child will receive therapy from both play therapists and parents trained in filial therapy, needs to be compared. For ethnic groups, the combination of filial therapy and play therapy may increase the sustainability of parents' play skills and decrease children's problems.

Background of Chinese Children's Behavior Problems
In China since the influx of industrialization and the implementation of a "one child" policy in the 1980s, remarkable changes have been emerging in traditional concepts, values, and lifestyles. Such dramatic changes have resulted in increasing stresses on family life and consequently in an increased prevalence of behavioral and emotional problems in Chinese children, from 3.3 -13.3% in the 1980s to 15.5% in the 1990s (Liu, Kurita, Guo, Tachimori, Ze, & Okawa, 2000). Despite the enormous differences between American and Chinese societies, parents and teachers reported quite similar rates of behavior and emotional problems for both urban and rural children ages 6 to 13 in the two countries (Weine, Phillips, & Achenbach, 1995). Chinese children who have no siblings have been found to be more aggressive or externalizing, more self-centered or individualistic, and more extroverted than children with siblings (Chang, Schwartz, Dodge, & Mcbride-Chang, 2003).
Psychosocial factors have played an important role in the development of behavior problems in Chinese children. Recent research revealed that behavioral problems in Chinese children were significantly associated with a number of psychosocial factors such as poor marital relations of parents. Separation or divorce of parents is the most significant factor (Liu, Kurita, Guo, Miyake, Ze, & Cao, 1999;Liu, Kurita, Sun & Wang, 1999). Among the multiple risk factors, parenting practices are critical predictors of aggressive and antisocial behavior (Webster-Stratton & Herbert, 1994). Recent studies reported that psychological and behavioral problems such as aggressive behavior, immature behavior, dependence, self-selection of diet, and obesity were prevalent in Chinese children due in large part to parental over-expectancy, over-involvement, and lack of basic knowledge in rearing children. Physical punishment for the Chinese child's misbehaviors is the strongest predictor after controlling for other factors . Chinese authoritarian parenting was associated positively with children's aggression and negatively with peer acceptance, sociability competence, and school academic achievement. In contrast, parental authoritative style was associated positively with social and school adjustment and negatively with adjustment problems (Chen, Dong, & Zhou, 1997). Harsh parenting has had a direct as well as an indirect effect on Chinese child aggression in the school environment through the mediating process of child emotion regulation (Chang et al., 2003). Noticeably, Chinese parenting has been affected by the contemporary Chinese culture in which academic success and cognitive development are emphasized as priorities of children's development. Thus children's playtime is reduced, and their emotional development is ignored.

Efficacy of Filial Therapy for Chinese Children
With the increase of children's problems in China, it is imperative for Chinese parents to be aware that they need to adjust their practices to address their children's problems. Intervention programs for children's problems are needed not only to reduce children's problems but to prevent parents' dysfunction as well. The central assumption for parenting training is that the deficiency of parents' skills is the major factor in the development and maintenance of conduct disorders (Webster-Stratton & Herbert, 1994). However, there are few parenting programs available in China to address these issues. Additionally, understanding the child and open expression of affection to the child are less advocated in the traditional Chinese parenting. By contrast, the focus of filial therapy is to enhance the parent-child relationship through understanding, empathy, acceptance, encouragement, and effective limit setting (Rennie & Landreth, 2000). In this regard, filial therapy may have unique meaning for Chinese children's problems.

Conclusions
Although the play media may differ, the need for children to communicate through play is a universal phenomenon across cultures. In other words, people are different in terms of language and values across cultures, but they are the same in sharing basic human needs. In this sense, the identification of apparent conflicts of unique values and common humanity will be the preliminary step for a researcher or clinician to implement a sensitive and acceptable intervention in another culture.
In respect to Chinese culture, the emphasis of hierarchy between parents and children and the strong awareness of stigma associated with mental problems are the major barriers to implement parenting management training in China. However, filial therapy appears to have the great potential for Chinese parents and children for two specific reasons.
First, a child is not taken to see a therapist, and the emphasis of filial therapy is on training parents to be the agent of change in their children's lives. To the extent they feel empowered to change the child's problems by themselves, the Chinese parents may not feel they are losing control or being forced to change. The consistently positive results of the two studies with Chinese immigrants have indicated their acceptance of filial therapy.

. . . filial therapy would be a promising intervention in China, by empowering
Chinese parents to be more empathic and understanding of their children.
Second, with the "one child" policy in China, Chinese parents and/or grandparents have been replacing the role of siblings in terms of playing. In this sense, it will be crucial for Chinese parents to learn how to interact with their children in terms of a child's languageplay. Therefore, the emphasis of play itself will be dramatically meaningful to build a communication bridge between Chinese parents and their children, and thus promote healthy development in Chinese children.
As a result, filial therapy would be a promising intervention in China, by empowering Chinese parents to be more empathic and understanding of their children.

Filial Therapy for Children's Behavioral and Emotional Problems in Mainland China
Meanwhile, this approach also offers children the use of their language of play to express themselves and release their conflicts and problems.