Application of Mindfulness Training in a Family-based Intervention for Improving Early Child Development and Stress Management in Economically Disadvantaged Families
Phase: NA
Conditions: Stress
Sponsor: The Hong Kong Polytechnic University

Cover page 
 
Official Title of the study: Family-based Mindfulness Training  
for Promoting Child Development and Stress Management  
in Economically Disadvantaged Families 
 
NCT number (if available): NCT ID not yet assigned 
 
Date of the document: September 18, 2017 
 

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Application of mindfulness training in a family-based intervention for improving 
development and stress management for children in economically disadvantaged families 
Study Objectives 
 
1. To investigate the effectiveness of a FBMI in reducing parental stress and promoting child 
development 
2. To develop an evidence-based practice approach for reducing stress of EDF in Hong Kong 
Chinese context. 
3. To add to theory and develop a better understanding of factors related to EDF and child 
development to aid policy makers and practitioners working with them 
 
Research plan and methodology 
 
Hypotheses of the study 
In responding to the objectives proposed in last section, we hypothesize that the children in the 
intervention will have lower physiological stress, less behavioral problems, better attention, 
behavioural and emotional regulation than participants in the control group at the end of 
intervention, and parents in the intervention will have lower physiological stress and self-reported 
parental stress, less anxiety and depressive symptoms, better mindfulness in parenting and 
perceived family functioning than participants in the control group at the end of intervention. 
 
Research plan  
The effects of this family-based intervention will be tested using a two-arm randomized controlled 
trial, comparing the family-based mindfulness intervention (arm 1) to a wait-list control (arm 2). 
After the completion of the programme and a three month follow-up, participants in arm 2 will be 
given the same intervention. Assessments will be made before (T1) and after intervention (T2) and 
at the three month follow-up (T3). Programme effects can be tested using both between-subject 
(comparison of two arms) and within-subject (comparison of measures at T1, T2, and T3). 
Sample size estimation. There are two primary outcomes in this study. Outcomes of two 
mindfulness training by Bogels and colleagues (2013), with an effect size of 0.4 in parental stress, 
and the one by Black and Fernando (2010), with an effect size of 0.4 in paying attention and 
selfcontrol, are chosen for sample size calculation. For a two-tailed α error of 5%, an 80% power, 
and a test of two independent groups, the required sample size will be 100 families per arm (Cohen, 
1988). With references to two local mindfulness training studies which reported 30% 
drop-out rate (Hou et al., 2013; Lo et al., 2013), we aimed to recruit 130 families per group, and 
260 families for two arms in total. 
Recruitment of participants. Considering the feasibility of recruiting a large number of economic 
disadvantaged families and the arrangement of intervention programme within their living district, 
three districts (Kwai Ching, Kwun Tong, and Sham Shui Po), which ranked the first, third, and the 
fourth among 18 districts in Hong Kong, in terms of percentage of the children aged 0 to 15 from 
low income families (Census and Statistical Department, 2013). All kindergartens joining the 
education voucher scheme which are affordable to low income families in above three districts 
will be assigned a random number. Kindergartens will be randomly selected, and all K2 and K3 

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parents from the kindergarten will receive an invitation to participate in this study. Interested 
participants will be assigned to two arms randomly. The randomization allocation is administered 
by an independent research assistant who is blind to the identity of participants and will not be 
involved in contacts with families and programme implementation. With the estimation of an 
average response rate of 40%, and a 33% of families in these districts are families in economic 
disadvantaged, 1500 invitations are required to meet the expected sample size. Quota will be 
divided by three districts according to their number of student populations proportionally. At the 
beginning of the study, parents of the participating schools will be asked to complete the parenting 
stress inventory and demographic information. Inclusion criteria of this study include: (1) monthly 
household income below one half of the median of those in Hong Kong; (2) moderate to high 
parental stress: to be assessed by a self-reported inventory Parenting Stress Index Short Form (PSI-
SF) (Abidin, 1990). A cut-off point of 100 is selected, as reported by Lam as the mean in her 
sample, and only parents with a PSI score of 101 or above will be included in this study. The only 
exclusion criteria will be children or parents with disability. Families are formed into groups of 20 
to 25 for programme implementation.  
 
Procedures 
Programme planning and training. The programmes for parents and children were developed by 
following the first three steps in intervention research, which was proposed to be completed a large 
scale of clinical trial was conducted (Feaser & Galinsky, 2010). First, develop programme theories: 
FMBI adopted themes and approaches about stress responses, with reference to the chronic 
situation of poverty, and promote the use of acceptance and approach coping in the programmes. 
Two evidence-based mindfulness training programmes were selected for further adaptation for the 
present project. The parent mindfulness training is a brief version of the Mindful Parenting course 
developed by Bogels and Restifo (2014). The evidence-based programme was originally 
developed for reducing the stress of parents of adolescents with ADHD or aggression (Bogels et 
al., 2013). The protocol for the child programme was developed by Eline Snel (2013), which was 
suitable for children at ages from 5 to 8. Concerning the suitability of a programme for coping 
with poverty-related stress, Wadsworth (2012) highlighted three major principles for promoting 
effective responses to stress: addressing the involuntary stress responses, appraising the 
controllability of the situation using approaching-oriented coping, and selecting coping method 
that matches the specific stressor. Both parent and children programmes follow the mechanisms 
of mindfulness training, assisting participants to address, acknowledge and accept difficult 
experiences, and develop self-care strategies or plan for mental health. For children programme, 
seeking help from adults including parents, caregivers, or other significant others in view of their 
own limitation of resources (Wadsworth, 2012). This component will be added to the 8 week 
mindfulness programme for children. 
Second, programme structure and processes in the intervention design. In the first draft of the 
parent programme contents were developed by the principal researcher. Five experienced 
mindfulness training instructors formed a practice team and gathered for providing comments to 
the session contents for three times before the pilot studies. Two overseas reviewers were further 
invited to comment the programme content and responded to the proposed areas of modification 
for finalizing the intervention protocol. Third, refinement of the protocol in pilot study. Pilot tests 
have been conducted in 2013/14. Minor modification was made in each of the three major 
components of a mindfulness-based intervention, namely, in-class mindfulness exercises, 

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discussion of relevance to context, and home exercises, after the second round of practice team 
meeting and consultation with overseas reviewers. 
Four instructors will be recruited to conduct the programmes. They should have a bachelor degree 
in social work, psychology, education, or nursing, and complete a basic eight week mindfulness 
training programme. They are required to complete instructor’s training, either a two day training 
for parent programme, or a six day training for child programme. Please refer to table 1 and table 
2 for the sessions outline for programmes for children and parents. 
The applicant has conducted two pilot studies to explore the feasibility of FBMI from May to 
October 2014. Pilot study 1 implemented to six children at 5 and found that they had improved in 
anxiety-depression symptoms (t=2.61, p=.05) and attention accuracy (t=2.63, p=.02). Pilot study 
2 was implemented to 10 parents and their children. (to be completed in two weeks). 
 
Implementation and assessment. After the first assessment (T1), the participating families in arm 
1 receive eight session mindfulness training. After the intervention, students in both arms will 
complete the second assessment of the study (T2). Participants in the wait-list (arm 2) will not 
receive any intervention during this phase. Each session lasts 60 minutes for children and 90 
minutes for adults and a 10 minute daily home practice is required. In view of the age factor, a 
smaller group size of 6 to 8 was adjusted for the children after the pilot study, and a size of 16 to 
18 remained for parent group. The class sizes are identical to the recommendation of mindfulness 
training programme as proposed by overseas training bodies and was confirmed by the overseas 
reviewers (Kabat-Zinn, 1990: Snel, 2013). Session plans of two programmes are attached in 
Appendix 1. Three Non-government organizations have committed to participate in the study. 
They are Hong Kong Family Welfare Society, Christian Family Service Centre, and Yang 
Memorial Methodist Social Service. Programmes will be conducted in their family service centres 
at Kwai Chung, Kwun Tong, and Mongkok. Each centre will be responsible for conducting 
intervention programmes for the families recruited within or in a nearby district. Participants in 
the wait-list (arm 2) will receive the same intervention after three month follow up (T3). 
Intervention fidelity. The intervention will be assessed for fidelity of implementation by 
videotaping all group sessions. Two independent experts in mindfulness training will be recruited 
to view six randomly selected clips and rate the level of compliance to the intervention protocol. 
High concordance rate between two experts signifies great fidelity to intervention. 
Additional qualitative studies to offset the threats of internal validity. 1. Parent’s weekly diary: 
The use of weekly diary for recording the use and reflection of homework exercises is a regular 
practice in MBCT (Segal, Williams & Teasdale, 2013). Weekly diary is also a common evaluation 
strategy to examine programme effect and it has also been used in local intervention study (Shek, 
2010). For each parent group, two parents will be randomly assigned to write up their experiences, 
feelings and thoughts about stress and their coping in daily life. Since the participants are from 
economic disadvantaged families, research assistants will confirm with selected participants if they 
are literate and feel competent to submit their diary. 2. Focus group interviews: All parents will be 
invited to participate in the 8th week and attend a focus group interview. They will be gathered 
face-to-face to reflect and share their perception about the programme and the changes their family 
experience after joining the programme. The procedure of the interview will be structured, 
addressing topics about participant’ overall conditions about their family stress, their reports of 
changes after joining the intervention programmes, their attributions about changes, and the 
helpful and unhelpful components of the programmes. The interview protocol is adapted from 
Client Change Interview (CCI) developed by Elliott, Slatick and Urman (2001). 

4 
 
 
Measures 
Figure 1 list out all variables and measures to be used in this study. 
Demographics. Questions about age and gender of parent and child, place of birth, number of 
family members and children, parent’s marital status, household income will be asked.  
Child functioning  
1. physiological stress. Salivary cortisol and HRV are useful biomarkers that have been selected as 
outcome measures for mindfulness-based intervention (Matousek, Dobkin & Pruessner, 2010; Nijjar 
et al., 2014). They are also useful stress indicators for young children (Blair et al., 2011a; Michels et 
al., 2013). 
Salivary cortisol: Salivary cortisol of both parents and children will be collected by Salivette tubes. 
Two saliva samples (wake up and 2100 h) at two time-points (T1, T2) on two consecutive days 
are used. The participants were reminded not to brush their teeth or eat within thirty minutes before 
sample collection to avoid contamination and were advised to follow their normal daily routines 
otherwise. Collected tubes were kept frozen until they underwent laboratory analysis of the 
salivary cortisol using an enzyme-linked immunoassay kit (Salimetrics, PA, USA). Heart Rate 
Variability (HRV): HRV is a measure of cardiac autonomic function by counting the cyclic 
variations of RR intervals in electrocardiogram. It is also an early marker of cardiovascular risk 
(Taylor, 2010). HRV will be measured by using ambulatory electrocardiogram to reflect on mother’s 
cardiovascular risk and autonomous nervous system functioning. Polar heart-rate monitors (Polar 
Vantage NV, Polar Electro Oy, Finland) will be used to continuously collect heart-rate data (in the 
form of R to R peak intervals) from the mothers for 30 mins. During the HRV assessments, the 
participants will be asked to do a stressful computer game to create an acute stressful environment. 
The participants’ spectral HRV data including (1) normalised low frequency (LF) power (0.04-0.15 
Hz), (2) normalised high frequency (HF) power (0.15-0.4 Hz) and (3) the low frequency/high 
frequency (LF/HF) power ratio will be recorded by using Kubios HRV version 2.1 software package 
(Biosignal Analysis and Medical Imaging Group, University of Eastern Finland, Finland).  
2. behavior problem. The Chinese-Cantonese version of Child Behavior Checklist (CBCL) will be 
used to assess child behaviour problems through collection of parent’s ratings (Achenbach & 
Rescorla, 2000). The test-retest reliability and criteria validity of the school children version of 
CBCL have been established for Hong Kong (Leung et al., 2006).  However, a preschool version 
CBCL/1.5-5 which applies to children aged 1.5 to 5 was developed in 2000 forming a similar 
factor structure in Mainland and overseas studies (Liu, Cheng, Leung, 2011). It has 67 items 
involving seven subscales (emotionally reactive, anxious/depressed, somatic complaints, 
withdrawn, aggressive behavior, attention problem, sleep problems). The first four was classified 
as internalizing problems and the following two was classified as externalizing problems, and such 
factor structure were confirmed in Mainland’s study. Correlations between seven subscales ranged 
from 0.38 to 0.71 and those between internalizing and externalizing problems was 0.75 (Liu, 
Cheng & Leung, 2010).  
 
3. attention. The Child Attention Network Test (ANT) was developed by Posner and Petersen 
(1990). It presents five fish in a horizontal row that appear above or below the fixation point. 
Children were instructed to press a key indicating in which direction the central fish was pointing 

5 
 
and to ignore the flanker fishes. Completion of the task allows calculation of three scores related 
to the efficiency of attention networks. Alerting is measured by the additional time required to 
respond with no cue, compared to a cue that inform the child that a target will occur shortly. 
Orienting is measured by the time taken to respond to a cue at the target location minus reaction 
time to a central cue. Executive attention is measured as interference by the flanker fish on the 
child’s score. The ANT was used in one of the Co-Investigator’s pilot study for mindfulness 
training for ADHD children (Wong, Kwok & Lam, 2012). 
4. emotion and behaviour regulation. A two dimensional assessment will be used and scores 
from both tests will be combined to form the child’s assessment of emotion and behaviour 
regulation. The Snack Delay and the Toy Wrap tests are used to assess the child’s emotional and 
behavioral regulation. In the Snack Delay test, children are instructed to put their hands flat on 
the table and watch a snack being placed under a cup. They can wait until the assessor tells them 
that “time is up” that they can have the snack. The assessor administers four trials, which last 10, 
20, 30, and 60 seconds respectively. The assessor scores each trial using a four point rating 
(1=eats snack, 2=touches snack, 3=touches cup or timer, 4=waits for time and does not touch cup 
or timer). The mean score across four trials will be the score of child’s emotional and behavioral 
regulation. In the Toy Wrap test children are asked not to peek while assessor wraps a toy in 
tissue and bag for one minute. The latency in seconds to first touch of toy will be measured. In 
the selection of test, a rule of not having more than 50 percent of participants got highest scores 
will be observed (Bassett, Denham, Wyatt, & Warren-Khot, 2012). Construct validity of this 
measure was evaluated in the applicant’s pilot study in 2014. In a study with 8 samples, the 
Snack Delay was significantly negatively correlated with emotionally reactive syndromes (r = 
-.82, p < .05), aggressive behaviors syndromes (r = -.79, p < .05), externalizing problems (r = 
-.80, p < .05) and total problems (r = -.73, p < .05) in parent-reported Child Behavior Checklist. 
In a study with 7 samples, the Toy Wrap was significantly negatively correlated with attention 
problems (r = -.80, p < .05), internalizing problems (r = -.86, p < .05), externalizing problem (r = 
-.77, p < .05) and total problems (r = -.84, p < .05). 
5. cognitive and language development. The Hong Kong Early Child Development Scale has 
been developed for assessing the children from three to six for their overall development 
conditions (Rao et al., 2013). Within the eight domains, language development (13 items), pre-
academic learning (27 items), and cognitive development (10 items) will be selected for the 
present study. Cronbach’s alphas of the above three subscales are .80, .95, and .70 respectively. 
Normative data for K3 students in Hong Kong is available for comparison (Rao et al., 2013). 
Parent functioning 
1. physiological stress. Salivary cortisol and HRV of parents and data collection follows same 
procedure as child salivary cortisol and HRV.  
2. parental stress Parenting Stress Index Short Form (PSI-SF) The Parenting Stress Index Short 
Form has 36 items and was developed by Abidin (1990) for tapping the sources of difficulties and 
level of parenting stress experienced by parents. The scale was divided into three subscales, 

6 
 
parental distress, parental-child dysfunctional interaction, and difficult child. The Chinese version 
was validated by Lam (1999). The reliability estimates for the total score and three subscales were 
0.92, 0.86, 0.82, and 0.86 respectively.  
3. mental health. Anxiety and depression symptoms are assessed by The Chinese-Cantonese 
version of Hospital Anxiety and Depression Scale (HADS), originally developed by Zigmond and 
Snaith (1983). It consists of two sub-scales with seven items related to the level of depression and 
anxiety respectively (Leung et al., 1993). The Chinese-Cantonese version of HADS shows good 
convergent validity with close correlation with both the Hamilton rating Scale of Depression 
(HRSD) and the Hamilton Rating Scale of Anxiety (HRSA) (Leung et al., 1999). The Cronbach’s 
alpha coefficients are .80 and .71 for the anxiety and depression subscales respectively and its 
split-half r is 0.86. 
4. interpersonal mindfulness. The Interpersonal Mindfulness in Parenting (IM-P) has 31 items that 
assess the parent’s quality of mindfulness in specific to their family context (Duncan, Coatsworth, 
& Greenberg, 2009). The original subscales include listening with full attention, emotional 
awareness of self and child, self-regulation in parenting relationship, non-judgmental acceptance 
of self and child, and compassion for self and child. The inter-item coefficient ranged from 0.45 
to 0.72. IM-P was found to mediate the effects of family-based mindfulness intervention 
(Coatsworth et al., 2010). A validation study of IM-P on Hong Kong parents with preschool 
children will be conducted by the P-I on late 2013. 
Analysis 
Quantative data: Baseline equivalence. The values of the primary outcome measures (i.e., parental 
stress and child behavior problem) at T1 will be compared among participants in the two trial arms. 
The outcomes at T1 and the treatment-condition variable will be used as the dependent variables, 
after controlling for age and sex of child. 
Intervention effects. All analyses were carried out according to the intention-to-treat approach. 
Missing values of participants were imputed using the last-observation-carried-forward method. 
With the between-subject design, the effectiveness of the programmes will be tested and compared 
using multilevel regression models. The trial-arm memberships will be dummy-coded, so that the 
family-based intervention group (arm 1) will serve as the reference group. The outcomes measured 
at T2 and the dummy variables will be used as the dependent and independent variables, 
respectively, controlling for the outcomes measured at T1 and other demographic covariates. For 
the within-subject design, four-level regression models (changes within parents, changes within 
children) will be used to examine the effects of the intervention programme. The time points will 
be dummy-coded, so that the outcome measures at T2 will serve as reference. The dependent 
variables are outcome measures, whereas the independent variables are dummy variables 
identifying the measurement time points. Demographic covariates are controlled. The T1-T2 
difference and the T2-T3 difference will be compared by testing the size of coefficients of the 
dummy-coded variables in the models using Wald tests. Reduction in the values of the outcome 
measures between T1 and T2 will indicate significant programme effects. The outcomes measured 
at T2 and T3 will be compared among arms 1 and 2 to see whether maintenance effects will be 
found around 3 months after the end of the programme. Using the same analytical techniques for 
the within-subject design, the models for testing maintenance effects will be conducted separately 
for participants in arm 1 and arm 2.  

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Qualitative data: Weekly dairies: Two research assistants will be assigned to rate the participant’s 
uses of mindful approaches in coping with stress in weekly diaries. Participant’s reports of benefits 
of mindfulness training in terms of frequency and areas of benefits (self, children, physical health, 
mental health, attention, learning and other cognitive functioning) will be counted in categories. 
Focus group interview: Contents of the interview will be transcribed and analyzed in a coding 
process. The text will be divided into small units (phrases, sentences and paragraphs) and labels 
will be assigned in each unit, and then codes will be grouped into themes (Creswell & Clark, 2011). 
Intra-rater and inter-rater reliabilities will be calculated 
 
 

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Project funding (in Hong Kong dollars) 
Research assistant $16 000 x 24 months X 0.6 x 1.05 (MPF) =$241 920 
Instructors fee $600 per session x 18 children groups + $1200 per session x 9 parent groups  
=$21 600 
Salivary cortisol analysis $120 per sample x 520 participants x 2 samples x 2 time points  
$124 800 
Cash coupon for program completers $200 per families x 200 =$40 000 
Miscellaneous $20 000  
Amount requested $448 320 
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Appendix 1 
 
Mindfulness training for children (developed by Eline Snel, 2013) 
 
Session 
Theme 
Goal 
1 
A for attention 
 establish motivation of be attentive and 
mindful 
 use breathing as a beginning of exploration 
of attention 
2 
Exploring our body 
 introduce mindful movement exercises 
 expand awareness of body sensation 
3 
Tasting, Smelling, Hearing, 
Seeing and Feeling 
 introduce the use of multiple senses in 
understanding our inner and outside world 
4 
Feel our feelings 
 learn to be aware and describe our feelings 
5 
Accepting feelings 
 acknowledge feelings of self and others 
 experience the importance of accepting 
feelings 
6 
Conscious movement 
 bring attention and awareness to self and 
others 
7 
The power of awareness and 
thoughts 
 experience the application of mindful 
attention and thoughts in daily life 
8 
Being nice is good 
 consolidate learning 
 celebrate  
 
 
Mindfulness training for parents  
 
Session 
Theme 
Goal 
1 
orientation 
 introduce mindfulness 
 Collection of baseline  
2 
Automatic reactions 
 introduce body scan (lying exercise) 
 understand the symptoms and stress 
reactivity notice physiological, emotional 
and cognitive reaction in stressful moments 
of parenting 
 use of mindful breathing and nonjudgmental 
attitude in managing the reaction 
3 
Understand our children 
 introduce mindful movement 
 Enhance attention and sensitivity to child’s 
developmental and emotional needs 
 develop nonjudgmental attitude to child’s  
behaviors 
4 
Respond to children mindfully 
 notice reactive patterns in parenting and 
communication 
 introduce three minute breathing as coping 

17 
 
 practice deep listening in mindfulness 
5 
Goals and expectations in 
parenting  
 notice different needs and wants of children 
and adults 
 identify healthy qualities for parents and 
children 
6 
Communicate with 
mindfulness 
 communicate needs and wants in parenting 
and family relationship 
7 
Self-care of parents 
 promote self-care for supporting children 
and family in adversity 
 consolidate learning 
8 
focus group interview 
 embedded for research purpose 
 investigate the mechanism of change 
 
 
 
 

18 
 
Figure 1 
Variables and measures of the proposed study 
 
 
 
Family-based 
mindfulness 
intervention 
Parent’s 
mindfulness 
(IM-P) 
Stress reactivity 
(cortisol & HRV) 
Parental stress (PSI) 
Family functioning 
(CFAI) 
Parent’s mental 
health (HADS) 
Child’s attention & 
behavior/emotional 
regulation (ANT & 
assessment)