J Child Fam Stud (2011) 20:272–278
DOI 10.1007/s10826-010-9388-1
ORIGINAL PAPER
Acceptability of Behavioral Family Therapy among Caregivers
in China
Jun Yu • Mark Roberts • Maria Wong •
Yongqiang Shen
Published online: 10 July 2010
 Springer Science+Business Media, LLC 2010
Abstract In the U.S., helping the noncompliant child and
parent child interaction therapy represent behavioral
family therapy programs that are empirically supported for
treating the conduct problems of 2- to 7-year old children.
This study examined how caregivers in China would view
behavioral family therapy. Caregivers in Hangzhou, China
reported the perceived age of deviance for behavioral
family therapy targets (e.g., noncompliance) and rated the
acceptability of behavioral treatment components (e.g.,
timeout). Chinese caregivers agreed with European-
American culture on considering noncompliance, aggres-
sion, tantrums, and negative talk deviant during the pre-
school period. Overall, Chinese caregivers considered all
the following nine behavioral family therapy components
acceptable: contingent praise, responsive play, ignoring
deviant attention seeking, authoritative instruction-giving,
warnings, chair timeouts, ignoring tantrums during time-
out, room backups for chair timeouts, and immediate
timeouts for aggression. However, specific parental reser-
vations were found regarding backup procedures for chair
timeouts, particularly room backups. Possible treatment
accommodations of behavioral family therapy for Chinese
families are discussed.
Keywords Behavioral family therapy

Disruptive child behavior
Treatment acceptability

Cultural accommodations
China
J. Yu
M. Roberts (&)
M. Wong
Department of Psychology, Idaho State University, Stop 8112,
Pocatello, ID 83209-8112, USA
e-mail: robemark@isu.edu
Y. Shen
Department of Psychology, Shanghai Normal University,
Shanghai, China
123
Introduction
Conduct problems among youth are significant in China. A
survey of 2,468 children ages 2–3 showed 3.2% prevalence
rate for externalizing problems (Liu et al. 2003). A recent
study of 9,089 children ages 4–6 found that the prevalence
for externalizing problems was 9.2% (Li et al. 2009).
Additionally, Guan (2006) found an 11% prevalence rate of
aggression among Chinese children ages 3–6, specifically,
13% for boys and 7% for girls. All of the above studies
used versions of the child behavior checklist (CBCL) that
were normed in China (Liu et al. 2003; Xin et al. 1992).
In the U.S., helping the noncompliant child (HNC)
(McMahon and Forehand 2003) and parent child interac-
tion therapy (PCIT) (Hembree-Kigin and McNeil 1995)
represent behavioral family therapy (BFT) programs that
meet the ‘‘probably efficacious’’ standards of Division 12
of the American Psychological Association (Eyberg et al.
2008) for treating the conduct problems of 2- to 7-year old
children. Initially targeting European-American families,
PCIT has been successfully adapted to Mexican-American
(McCabe et al. 2005), African-American (Coard et al.
2004), and Native-American cultures (BigFoot and Fund-
erburk 2006). Adaptations have also been attempted for
Puerto Ricans (Matos et al. 2006) and in some other parts
of the world including Australia, Hong Kong, the Nether-
lands, and Norway (McNeil and Hembree-Kigin 2010). In
contrast, BFT approaches for treating disruptive child
behavior in mainland China are virtually non-existent.
A search of the Chinese literature found only one article
briefly describing PCIT (Zhang and Lu 2008). There is also
a remarkably limited literature on the professional treat-
ment of Chinese 2–7 year-old children’s behavior prob-
lems. Interventions studied by Chinese professionals
include sand-play therapy (Long 2008), Adlerian mutual
J Child Fam Stud (2011) 20:272–278
storytelling therapy (Zhao 2007), social skills training
(Wang 2006; Wang et al. 2007), sensory integration
training, and child-rearing guidance (Yu et al. 2006; Zhao
et al. 2007). All Chinese interventions were found to be
more effective than no-treatment. Sensory integration
training and child-rearing guidance, however, required up
to 3 years to complete, compared to the typical 2–3 months
for standard HNC/PCIT programs. The effects of story-
telling therapy and social skills training were limited by
children’s language development. Most importantly, all of
these interventions failed to target specific externalizing
problems (e.g., noncompliance). Clearly, the Chinese
CBCL normative comparison data and treatment literature
indicate a need for empirically supported BFT programs
like HNC or PCIT to treat disruptive behavior problems in
China. The next step would seem to be an empirical trial in
China.
However, it is unknown how Chinese caregivers
(mothers, fathers, and grandparents) would view BFT.
First, do Chinese caregivers agree with BFT treatment
goals? Second, how acceptable are BFT intervention
components among Chinese caregivers? The current study
examined these two questions, both of which are linked to
the social validity of a treatment (Wolf 1978). Social
validity refers to the subjective value judgment by a society
about the social significance of treatment goals (i.e., do
Chinese caregivers really want the BFT goals?), the social
appropriateness of the treatment procedures (i.e., do Chi-
nese caregivers consider BFT procedures acceptable?), and
the social importance of treatment effects (i.e., are Chinese
caregivers satisfied with the results?) (Wolf 1978).
Treatment goals relate directly to the presenting prob-
lems that lead a client to seek treatment (Foster and Mash
1999). If Chinese caregivers disagree with BFT treatment
goals, then they would not seek BFT nor consider BFT
relevant. BFT generally targets four typical disruptive
behaviors among children ages 2–7 years: noncompliance,
aggression, tantrums, and negative talk (Roberts 2008). If
Chinese caregivers consider these disruptive behaviors
unacceptable in 2- to 7-year-old children, they should be
motivated to seek professional assistance. Consistent with
this possibility, Chinese culture values group harmony and
moderation such that a lack of behavioral and emotional
control is considered problematic (Cen et al. 1999; Ho
1986). Confucian teachings emphasize parental training of
children to be well mannered and manifest behavioral
composure, affective control, and gentle speech (Wu
1996). Child compliance, self-control, and limit setting are
among the main parenting beliefs in contemporary Chinese
mothers of 2- to 6-year-old children (Li et al. 1997). Chi-
nese parents often begin to discipline child aggression
around 2.5 years of age (Ho 1986). Therefore, it is
hypothesized that Chinese caregivers would agree with the
273
BFT goals to treat the basic four disruptive behaviors of 2-
to 7-year-old children.
Treatment acceptability refers to the extent to which
potential consumers of a treatment perceive each procedure
as appropriate, palatable, and effective (Kazdin 1981).
Acceptable treatments are related to increased cooperation,
compliance, therapeutic change, and effectiveness of the
intervention (Kazdin 1980, 2000). Underutilization of
interventions among US minority families has been linked
to poor perceptions of treatment acceptability (Krain et al.
2005). Parents from different cultures are less likely to
employ a skill that is viewed as inappropriate or unac-
ceptable (Forehand and Kotchick 1996).
The BFT procedures include two treatment stages rec-
ommended by both HNC/PCIT programs. In Stage I, par-
ents are taught to react positively to age-appropriate child
signals in a play context, referred to as ‘‘The Child’s
Game’’ (HNC) or ‘‘Child-Directed Interaction’’ (PCIT).
Inappropriate attention-seeking (e.g., pout, whine, com-
plain) is ignored, hence, providing a differential attention
regimen to motivate age appropriate play and a mechanism
to possibly enhance parent–child attachment (Foote et al.
1998). In Stage II, referred to as ‘‘The Parent’s Game’’
(HNC) or ‘‘Parent-Directed Interaction’’ (PCIT), parents
are taught to motivate child compliance by the use of clear
direct instructions, social reinforcement for compliance,
and consistent discipline for noncompliance. Specifically,
parents are taught to praise child compliance initiations,
warn the child for continued noncompliance, use a chair
timeout (TO) system for noncompliance to warnings, and
apply room backup procedures to motivate the child to
remain on the TO chair. The current study identified nine
BFT treatment components for evaluation by Chinese
caregivers: contingent praise, responsive play, ignoring
deviant attention seeking, authoritative instruction-giving,
warnings, chair TOs, ignoring tantrums during TO, room
backups for chair TOs, and immediate TOs for aggression
(i.e., a ‘‘standing rule’’).
To date, no studies have researched the acceptability of
all the major components of BFT. Nevertheless, quite a few
studies have examined the acceptability of several HNC/
PCIT treatment components among American samples.
Cross-Calvert and McMahon (1987) studied 90 nonreferred
mothers of young children ages 3–8 and found rewards,
commands, and attends were rated as more acceptable than
TO and ignoring. All five HNC techniques, however, were
rated very positively. Jones et al. (1998) examined
acceptability of six behavioral techniques among 20
mothers of children with disruptive behavior disorder.
They found positive reinforcement was rated as a more
acceptable treatment technique than response cost, TO,
differential attention, overcorrection, and spanking. Masse
(2006) found no differences between Native and Non-
123
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Native American parents with regard to acceptability of
behavioral parenting training. Borrego et al. (2007) found
response cost, a discipline procedure, more acceptable than
positive reinforcement-based techniques (e.g., differential
attention) for Mexican-American parents. Clearly, even
among various American samples, there is a difference in
opinion about the acceptability of treatment techniques.
Nevertheless, even the disciplinary components are found
to be acceptable, which is consistent with the application of
Stage II interventions which place strict limits on non-
compliance and aggression.
The current study is the first to examine acceptability of
BFT treatment components among Chinese caregivers. It
was predicted that the BFT components would be per-
ceived as acceptable, since increasing child compliance is a
treatment goal consistent with Chinese culture. Addition-
ally, mainland Chinese caregivers might perceive differ-
ential attention (i.e., contingent praise) as a less acceptable
strategy to manage child disruptive behavior, since Chinese
parents in Hong Kong were found to be hesitant to use
praise in therapy (Ho et al. 1999; Leung et al. 2009). In
contrast, the BFT control procedures (Stage II) might be
perceived as more acceptable than praise and play com-
ponents (Stage I), since Chinese families place strong
emphasis on conformity, obedience, and discipline (Ho
1986).
Therefore, the purpose of the current study was to
examine the social validity of BFT goals and procedures
among caregivers in mainland China. First, the perceived
ages of deviance of noncompliance, aggression, tantrums,
and negative talk were determined by sampling the beliefs
of Chinese caregivers. Second, the acceptability of BFT
components among Chinese caregivers of young children
was evaluated.
Method
Participants
Caregivers (N = 183) were recruited from preschools in
Hangzhou, a region in East China with a population of
about eight million. Caregivers were mothers, fathers, and
grandparents from different families and were self-identi-
fied as the primary caregiver for the target child. Most
respondents were mothers (75%), but some fathers (18%)
and grandparents (7%) participated in the study. The mean
age for mothers was 32 years (SD = 2.7), for fathers,
35 years (SD = 3.8), and for grandparents, 56 years
(SD = 2.6). The caregivers’ education level included: 67%
college; 22% high school; 7% middle school; and 5%
elementary school. The mean annual household income for
the 114 caregivers who reported income was 137,895
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J Child Fam Stud (2011) 20:272–278
Chinese Yuan (about $20,684 US). Children’s mean age
was 4.3 years (SD = 1.2). Forty-seven percent of the
children were living with grandparents in the 101 families
that answered our question about extended kin living with
the child. Children were balanced for gender (48% male;
52% female) and virtually all were only children (89%),
consistent with the current Chinese culture.
Measurements
Demographics Questionnaire
Data collected included caregivers’ age, relation to child,
education, and annual household income, as well as the
child’s age, sex, siblings, and extended kin living with the
child.
Perceived Deviance Questionnaire
Four major BFT target misbehaviors were briefly descri-
bed: noncompliance, aggression, tantrums, and negative
talk. For example, noncompliance was defined as
‘‘…willful act of refusing to initiate actions or cease
actions when clearly instructed to do so by the parent or
other caregivers.’’ Each caregiver indicated the age at
which each misbehavior was perceived to be deviant.
‘‘Deviant age’’ was operationalized as the age by which the
misbehavior should no longer occur and should indeed be
treated if it persisted.
Treatment Acceptability Questionnaire
Nine specific BFT treatment components were briefly
described, along with a rationale for each component’s use.
For example, the BFT component ‘‘Chair Timeouts’’ was
introduced to Chinese caregivers by stating: ‘‘Parents are
taught to discipline misbehaviors with brief social isolation
(2–5 min) on a timeout chair. Chair timeouts are effective
at disciplining misbehaviors in 2- to 7-year olds because
the child is briefly removed from all sources of reinforce-
ment (no adult attention, no toys, and must remain on
chair).’’ The nine BFT components evaluated were: Con-
tingent Praise; Responsive Play; Ignoring Deviant Atten-
tion Seeking; Authoritative Instruction-giving; Warnings;
Chair Timeouts; Ignore Tantrums during Timeout; Room
Backup for Timeout; and Immediate Chair Timeouts for
Physical Aggression. Caregivers evaluated the acceptabil-
ity of each component by completing a modified version of
the Treatment Evaluation Inventory-Short Form (TEI-SF;
Kelley et al. 1989). The original TEI-SF includes nine
items that are designed to evaluate the acceptability of a
given treatment. The current study used six TEI-SF items
that have consistently loaded high on an ‘‘Acceptability’’
J Child Fam Stud (2011) 20:272–278
factor in Kelley et al. (1989). The key words for the six
items are ‘‘acceptable’’, ‘‘willing to use’’, ‘‘like’’, ‘‘effec-
tive’’, ‘‘improvement’’, and ‘‘reaction’’. Three of the six
items were reverse keyed in the current study to eliminate
response bias (i.e., always endorsing the same Likert Scale
anchor, such as ‘‘Strongly Agree’’). The resultant modified
TEI-SF, hereafter referred to as the Treatment Accept-
ability Questionnaire (TAQ) is a 6-item, 5-point Likert
scale (where 0 = strongly disagree to 4 = strongly agree).
Scores for each treatment component ranged from a min-
imum of 0 to a maximum of 24, where any average score
above 15 reflected minimum acceptability, since 15 was
half way between an average item acceptability rating of
‘‘Neutral’’ and ‘‘Agree’’. The alpha coefficients of the TAQ
for the 9 treatment components ranged from .79 to .91.
Results
The average age at which the four targeted misbehaviors
were perceived to be deviant were: noncompliance
3.5 years (SD = 1.4); aggression 3.4 years (SD = 1.3);
tantrum 3.7 years (SD = 1.6); and negative talk 4.1 years
(SD = 1.7). A 4 (misbehaviors) 9 3 (caregivers) repeated
measures ANOVA revealed a significant misbehavior
effect, F(3, 377) = 3.99, p \ .01, indicating that the per-
ceived ages of deviance were significantly different. Post
hoc least significant difference (LSD) comparisons indi-
cated that aggression was considered deviant at a younger
age than both tantrums and negative talk.
Figure 1 shows the means and standard deviations (in
brackets) for the acceptability ratings for each treatment
component. All components received average acceptability
scores above ‘‘neutral’’ (M = 12). Contingent praise,
responsive play, and ignoring received average acceptability
scores above the rational cutoff of 15. All remaining com-
ponents earned ratings below 15. A 9 (treatment compo-
nents) 9 3 (caregivers) repeated measures ANOVA
revealed a significant component effect, F(6, 1149) =
19.56, p \ .001, indicating significant differences in
acceptability among the nine treatment components. Post
hoc LSD pairwise comparisons showed that contingent
praise and responsive play were rated significantly higher
than the other seven components. Pairwise comparisons also
indicated that room backups for chair TOs were evaluated
significantly less acceptable than all other components.
There were no significant differences in acceptability among
the following treatment components: ignoring deviant
attention seeking, authoritative instruction-giving, warn-
ings, chair TO, ignoring tantrums during TO, and immediate
TOs for aggression. The treatment by caregiver interaction
was also significant, F(13, 1149) = 1.80, p \ .05. There-
fore, the differences in component acceptability varied by
275
type of caregiver. Consequently, one-way ANOVAs were
used to compare mothers’, fathers’, and grandparents’
acceptability ratings for each component. See Table 1 for
means and standard deviations of component acceptability
across caregiver types. Mothers (M = 18.1, SD = 3.3)
found praise more acceptable than grandparents (M = 16.0,
SD = 3.3). Additionally, mothers (M = 16.4, SD = 4.1)
rated ‘‘ignoring deviant attention seeking’’ more acceptable
than fathers (M = 13.2, SD = 4.8). Caregivers did not dis-
agree significantly about any other treatment component.
Discussion
This study sought to examine the social validity of BFT
among caregivers in China, focusing on treatment goals
and acceptability of treatment procedures. Chinese care-
givers agreed with BFT treatment goals in that they per-
ceived child noncompliance, aggression, tantrum, and
negative talk to be deviant by 3–4 years of age. Chinese
caregivers considered praising good behavior and respon-
sive play to be the most acceptable treatment procedures,
while room backups for chair TOs were the least accept-
able; no treatment procedure was considered unacceptable
(i.e., all mean acceptability ratings were above the neutral
point of 12 on the Likert scale).
The finding that these Chinese caregivers considered
continued noncompliance, aggression, tantrums, and neg-
ative verbalizations after the age of 3–4 provides support
for the potential utility of BFT in China. The Chinese
perceived age of deviance around 4 years old is within the
2–7 years age range for the HNC/PCIT treatment protocol,
which suggests Chinese caregivers’ beliefs are consistent
with BFT goals. If it were known to Chinese caregivers that
disruptive child misbehavior can be effectively managed
and that effective services were available, Chinese parents
with defiant, coercive 4-year olds might readily avail
themselves of such services.
Moreover, Chinese caregivers perceived BFT treatment
components to be acceptable. Differential degrees of
acceptance, however, were detected among the nine com-
ponents. Chinese caregivers considered positive strategies
(i.e., socially reinforcing compliance and general respon-
sivity during play) more acceptable than the other seven
BFT components. This finding is consistent with data from
European American caregivers (e.g., Cross-Calvert and
McMahon 1987; Jones et al. 1998). However, this finding
contradicts the reports that Chinese parents in Hong Kong
are hesitant to use praise (Ho et al. 1999; Leung et al.
2009). Results from current study suggest that mainland
Chinese caregivers find contingent praise and responsive
play at home to be acceptable parenting strategies.
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Acceptability among Chinese Caregivers

19

17.9 (3.3) 17.8 (2.9)

18

17
TAQ Score
16 15.6 (4.4)

15
14.5 (3.5) 14.3 (3.7)
14.1 (4.3)
14.0 (4.2) 14.0 (3.7)
14
13.1 (4.0)
13

12
Contingent Responsive Ignoring Authoritative Warning Chair Ignoring in Room Immediate
Praise Play Instruction Timeout Timeout Timeout Timeout
BFT Components

Fig. 1 Treatment Acceptability Questionnaire (TAQ) scores for the nine behavioral family therapy (BFT) components among all Chinese
caregivers

Table 1 Treatment acceptability of BFT components across Chinese caregivers

Mothers (n = 135) Fathers (n = 33) Grandparents (n = 12)
BFT component M SD M SD M SD

Contingent praise 18.1 3.3 17.6 3.0 16.0 3.3

Responsive play 18.0 3.0 17.3 2.8 17.0 2.3
Ignoring 16.4 4.1 13.2 4.8 13.4 4.4
Ignoring in timeout 14.6 3.3 14.1 4.4 13.7 4.7
Immediate timeout 14.2 3.6 14.7 4.1 14.4 4.0
Authoritative instruction 14.2 4.4 14.1 3.7 13.4 4.7
Chair timeout 14.1 3.4 13.7 4.5 13.3 4.8
Warning 14.0 4.1 14.1 4.7 13.7 4.3
Room timeout 13.3 4.0 12.8 4.3 11.1 4.3

In contrast, the more disciplinary components of BFT
received relatively low ratings. This could be a major
barrier to treatment utilization if not accommodated in
some manner more consistent with Chinese child care
practices. In European-American culture, enforcing chair
TOs with room TOs appears to be an important treatment
component for overtly noncompliant children (Roberts
2008). Overtly noncompliant preschoolers fiercely resist
initial chair TOs (Roberts 1982). If parents allow non-
compliant children to escape from chair TOs, compliance
acquisition is significantly attenuated (Bean and Roberts
1981; Roberts and Powers 1990). Room backups to chair
TOs (Day and Roberts 1982; Roberts 1988) have suc-
cessfully replaced the spanking contingency used by Hanf
(1969), whose program served as the basis for the modern
HNC and PCIT programs. Most importantly, noncompli-
ant, TO resistant young children in European-American
samples quickly adapt to the contingencies and rarely even
require a chair TO, let alone a room TO backup, after the
first month of home use (Roberts and Powers 1990).
Despite the apparent need for a disciplinary treatment
component, parents in European-American cultures also
rate TO and the associated backup systems relatively
poorly (Cross-Calvert and McMahon 1987). Nevertheless,
participants in BFT programs tolerate the disciplinary
procedures and strongly embrace the programs in general
(e.g., Forehand et al. 1980; Schuhmann et al. 1998).
What treatment accommodations might exist for a
Chinese constituency? Parent concerns about child safety
and trauma in room TO backup (Yu and Roberts 2010)
might be related to housing conditions and parenting
practices in China. Most Chinese families in cities and
towns live in tall buildings with relatively small apart-
ments, yielding a potential TO backup room cluttered with
objects. Under such TO conditions, angry young children
might act in a dangerous, destructive, or self harming

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manner, heightening caregivers’ concerns about children’s
safety. Moreover, Chinese caregivers rarely leave young
children alone, even during sleep. Wang et al. (2008) found
that 62% of Chinese children under age six sleep with their
parents in the same bed and 25% sleep in the same room.
One possible accommodation might embrace a fading
procedure using the parent’s proximity to reduce child
fears and parental concerns about brief social isolation in a
backup room. For example, if the child attempts to escape
the TO chair, the parent could guide the child to the bed-
room and stand silently and authoritatively inside the room
by the door. In addition, the parent’s proximity could be
gradually faded from within touching distance to the more
typical line-of-sight in the same room. Apparently, parents
could be provided with these or other options; and as in all
BFT programs, home data could be used to inform parent
and therapist if adjustments are needed.
A small set of caregiver differences were present in our
data set. Chinese mothers found contingent praise more
acceptable than grandparents, and mothers rated ignoring
deviant attention seeking more acceptable than fathers. The
difference among caregivers would have to be addressed
by therapists, since inconsistency among caregivers is a
risk factor for child misbehavior (Wei et al. 2007) and is
likely to adversely affect the outcome of BFT. In addition,
Chinese children cared for by grandparents have shown
more behavioral problems than those who were under
parental care (Wei et al. 2007). Considering the fact that
47% of children in our sample lived with grandparents, any
inter-generational or inter-caregiver disagreements must be
resolved prior to implementation of a therapeutic routine.
Several limitations should be considered when inter-
preting the findings of this study. First, our sample was
recruited from the community of Hangzhou. They were not
caregivers of clinic-referred children with disruptive
behavior problems. Clinical populations in China might
evaluate BFT components differently. Second, the majority
of our sample was college educated. It is important to
gather more information regarding BFT evaluations in
samples with less education. Third, only one caregiver
from a family participated. It may be useful to collect data
from multiple caregivers, as caregivers from the same
family may have different opinions regarding the accept-
ability of BFT. Finally, BFT components were evaluated in
isolation. Were caregivers to rate each component upon
completion of the entire treatment protocol, a different
picture might emerge. Nevertheless, the current study
found that Chinese caregivers agreed with European
American parents that persistent noncompliance, aggres-
sion, tantrums, and negative talk in parent–child interaction
should gradually cease during the preschool period.
Moreover, treatment components of the empirically sup-
ported HNC/PCIT protocols were judged to be acceptable,
277
albeit with relative preferences for more positive parenting
strategies. Therefore, it appears culturally acceptable to
perform clinical trials using HNC/PCIT treatment compo-
nents in China where to date, no such programs are
available, despite apparent need. Certainly, all applications
of any treatment protocol must consider individual and
cultural differences which would guide accommodations
like those discussed above.
Acknowledgments Part of this data was presented as a poster at the
World Congress of Behavioral and Cognitive Therapies, Boston, MA,
USA, June 2010. The authors thank all the volunteer participants and
the following individuals for their assistance to the project: Guozhen
Cen, Yiyuan Xu, Linyan Su, Luyi Du, Xiaojuan Wei, Xuzhen Ma,
Yazhen Zhou, Chengfeng He, Guobing Zhang, Hao Yu, Xiaoxian
Gan, and Fang Chen.
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