Effects of a Brief Mindful Parenting Program for Hong Kong Chinese Impacted by Social Unrest: A Randomised Trial
Phase: NA
Conditions: Mental Health Issue
Sponsor: The Hong Kong Polytechnic University

 
 
 
Cover page  
 
Official title of the study: Effects of a Brief Mindful Parenting 
Program for Hong Kong Chinese Impacted by Social Unrest: A 
randomized trial 
 
 
NCT number: to be assigned 
 
Date of the document: November 28 2019 
 
 
 
 
 
 
 
Principal Investigator 
Dr. Lo Hay Ming Herman, Hong Kong Polytechnic University 
 
 
 
 
For research team internal use only 
Please do not share with others without the permission of 
principal investigator. 
 
 
 
 
 
 

 
BACKGROUND RESEARCH 
 
Since the 2014 umbrella movement, there has been increasing research interest in how social unrest affects 
family relationship. A qualitative study found intra-familial conflict and different levels of renegotiation in 
the family relationships of active participants and bystanders in the movement (Ho et al., 2018). Another 
study of young adults and their family members reported that lower relationship quality and lower 
congruence in their political attitudes predicted more serious subsequent family conflicts, suggesting a close 
relationship between political and family life (Chan et al., 2018). The study also suggested that some families 
may have stronger resilience, while others experience serious and persistent conflicts. 
 
This division between the generations matches with the findings of some earlier studies. For example, A 
greater dissatisfaction has been found among the young than the older generation (Wong, Zheng, Wan, 2017). 
This observation is consistent with the trend of the younger generation’s growing participation in the political 
movement as they search for a way to express their dissatisfaction towards existing social and political 
structures (Lam-Knott, 2018). However, expectation of total obedience of children and a lack of personal 
space to express dissatisfaction are still common in many Hong Kong families (Shek & Sun, 2014). However, 
parental behavioural and psychological control predict adolescent risk behaviour (Shek, 2007). There should 
be a reconsideration of the overemphasis on family harmony and strict parental control, and a search for 
parenting principles that balance younger family members’ need for security and identity with continuing 
family bonding. 
 
Studies have shown that social unrest and exposure to community violence have a strong detrimental impact 
on adolescent mental health (Vorhies, Guterman, & Haj-Yahia, 2011). A supportive family environment is 
the most consistent mediator of this impact (Cummings et al., 2009). Studies in Northern Ireland, where a 
significant proportion of adolescents were exposed to community conflict, emotional insecurity and family 
cohesion predicted subsequent adolescent delinquency and aggression (Cummings et al., 2016; Taylor et al., 
2016). Mental health issues, particularly post-traumatic stress (PTS), are common in social unrest, but they 
are moderated by positive parental mental health and positive parenting (Dubow et al., 2012).  
 
Post-traumatic stress is caused by actual or threatened death or serious injury, direct exposure to violence, 
witnessing a significant person’s exposure to violence or an accident, or indirect exposure through hearing 
aversive details of the event (American Psychiatric Association, 2013). Core symptoms of PTS include re-
experiencing the trauma, avoidance, and a persistent sense of threat. Prolonged PTS may lead to issues with 
affective dysregulation, negative self-concept, and relationship disturbances (Cloitre et al., 2018). Studies 
indicate that 6–20% of individuals develop post-traumatic stress disorder after a potentially traumatic event 
(Kahana et al., 2006). Other mental health issues including depression, anxiety, paranoid ideation, and 
aggression have been found in adolescents with extensive exposure to community violence (Al-Krenawi & 
Graham, 2012). Adolescents living with parents who have different life values and exert high psychological 
control may lack a buffer against the threat of mental health problems during social unrest. Thus, this age 
group is at the highest risk of developing chronic mental health issues after exposure to traumatic life 
experiences (de Jong et al., 2015). 
 
Two core mechanisms – security and connection, and emotion regulation – are crucial to adolescent mental 
health in a context of social unrest. This project aims to support parents so that they can provide a safe and 
trustful environment to meet adolescents’ needs after experiencing traumatic events (Gewirtz, Forgatch, & 
Wieling, 2008). Given the current social unrest, parents and adolescents need emotion regulation strategies 
that can promote positive affective change and facilitate empathy and reconciliation in families and 
communities (Cehajic-Clancy et al., 2016). 
 
The content design of prevention and intervention programmes combines mindfulness skills with 
psychoeducation as a strategy for promoting security, connection, and emotion regulation (Chambers et al., 
2009). Mindfulness training has been widely adopted as a therapeutic approach for reducing emotional 
distress and promoting psychological well-being, including PTS (Banks et al., 2015; Gu et al., 2015). A study 
in Israel showed that after being presented with anger-inducing information related to political conflict, 
participants in a mindfulness workshop were more supportive of conciliatory policies and the effect was 
mediated by a reduction in perceived threat and improvement in emotion regulation (Alkoby et al., 2017). In 
emotionally charged situations that may lead to verbal and physical aggression, mindfulness on the soles of 
the feet is a specific technique that enable individuals to manage their emotional arousal by shifting the focus 
of attention to a neutral physical body part (Singh et al. 2011). A recent study of Chinese adolescents 
suggested that teaching parents Mindfulness on the Soles of the feet could reduce the aggressive behaviour 
of their adolescent children (Ahemaitijiang et al., 2019). A pilot study of Hong Kong secondary school 
students is in progress. 
 

 
Hypotheses of the study 
The current study will test the following three hypotheses based on the literature:  
(i) 
Parents participate in a brief mindful parenting program will experience less depressive symptoms, 
anxiety symptoms, post-traumatic stress symptoms, family conflicts, and higher family functioning and 
interpersonal mindfulness than parents from wait-list control.  
(ii)      Effects of the program will sustain at 3-month follow up. 
(iii) 
Parents with higher exposure to political unrest will predict the severity of the symptoms at pretest 
and follow-up. 
 
RESEARCH PLAN AND METHODOLOGY 
 
Study design 
This study uses a multi-site, randomized control trial. The effects of this intervention will be tested using a 
two-arm randomized controlled trial, comparing the mindful parenting program (Arm 1), to waitlist control group 
(Arm 2). Assessments will be made before (T0), 1-month follow up (T1), and 3-month follow-up (T2). The 
programme effects will be tested using both between-subject (comparison of the two arms) and within-
subject (comparison of measures at T1, T2, and T3). 
 
Sample size estimation. An estimated 340 parents will be recruited and randomised into an intervention group and a wait-
list control group. The sample estimation is based on an expected effect size of .33 for family functioning in the PI’s pilot 
study, with an estimated drop-out rate of 15%, a two-tailed α error of 5%, 80% power, and a test of two independent groups.  
 
Recruitment of participants. Inclusion criteria are: (1) parents of an adolescent with the age between 10 to 
21; (2) parents with a score of Patient Health Questionnaire (PHQ-9) score of 2 or above. Exclusion criteria 
are: 1) parents with current self-reported psychiatric diagnoses of psychosis, alcohol or substance abuse, 2) 
parents experiencing personal or family crisis in last six months; (3) parents cannot speak Chinese. 
   The research project will be announced and promoted in five non-governmental organizations, and social 
media. All interested parents will be given an information sheet and a four minute video explaining the 
nature of the study. After providing consent to participate the study, a research assistant who is blinded to 
the personal data of the participants, will   administer   the   random   assignment   using   computer    
generated programming. Participants will be randomly assigned to mindful parenting program (Arm 1), or 
waitlist control group (Arm 2).  
 
Procedures 
Program plan. The themes and content are based on a brief mindful parenting program developed by the same 
principal investigator (Lo et al., 2016, Lo et al., 2019). Psychoeducation of stress and coping in the context of 
parenting relationship is infused. Instructors for the program possess a PhD in psychology or social work, 
a specialist in psychiatry, and foundational professional training in mindfulness-based cognitive therapy. 
 
Implementation and assessment. After the first assessment (T0), caregivers who meet inclusion criteria will 
be randomized into Arm 1 or Arm 2. After the intervention, two time points will be used to assess the 
intervention outcome and sustainable effect at one month and three month. Programs are delivered in group 
format and will be conducted in five sits, including the P-I’s university and the service units of NGO 
collaborators. To ensure intervention fidelity, all program sessions will be audio-recorded and an 
independent rater will listen to 20% of the selected clips on random basis, and assess whether each element 
in the intervention protocol has been implemented with consistency. Higher concordance rates will signify 
greater fidelity to the intervention protocol, which will be carefully monitored throughout the study.  
 
An Ethical approval for this study has been obtained from the Research Office of the Hong Kong 
Polytechnic University. 
 
Measures 
All measures of the variables are summarized in Table 1 below. In line with the study objectives and 
hypotheses, primary outcome variables include parental depression. Secondary outcome measures include 
anxiety, post-traumatic stress, perceived family functioning, family conflicts, and interpersonal 
mindfulness. 
 
Data Analyses  
Quantative data analyses: Intervention effects. All analyses will be carried out according to the intention-
to- treat approach. (Moher et al., 2010). MANOVA will be used to evaluate the effects of the mindful 

 
parenting (Arm 1), relative to waitlist control group (Arm 2), and the analyses of the primary and secondary 
outcome measures. In addition to the immediate programme effects, outcomes measured at T1 and T2 will 
be compared, to assess whether maintenance effects will be sustained at 3-months. 
 
Table 1. Outcome variables and measures 
Study variables and measures 
Depression 
- Measured by the Patient Health Questionnaire (PHQ-9, Kroenke et al., 2001), 9 items 
Anxiety 
- Measured by the Generalized Anxiety Disorder 7-item (GAD-7, Kroenke, et al., 2016), 7 items 
Post-traumatic stress 
- measured by the International Traumatic Questionnaire (ITQ, Cloitre et al., 2009), 6 items 
Family functioning 
- Measured by 5 item, Family APGAR Scale (Smilkstein, Ashworth, & Montano, 1982), with five subscales 
in adaptation, partnership, growth, affection, and resolve.  
 
Family conflict 
- measured by Conflict Tactics Scale (CTS-2, Straus & Gelles, 1979), 16 items 
Interpersonal mindfulness 
- measured by the Interpersonal mindfulness in Parenting Scale (Duncan, 2007, Lo et al., 2018).