International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 A PILOT PROGRAM TO PROMOTE MENTAL HEALTH AMONG ASIAN- AMERICAN IMMIGRANT CHILDREN AND THEIR PARENTS: A COMMUNITY-BASED PARTICIPATORY APPROACH Tsu-Yin Wu and JooHyun Lee Abstract: A mixed-methods study evaluated the perceived effectiveness of a brief, community-based parenting intervention for Asian immigrant families in the United States. A community sample of twelve parent-child dyads (consisting of both foreign- born and U.S.-born children) participated in four-week long psychoeducational workshops on the mental health issues facing Asian-American immigrant families, and effective parent-child communication. The effectiveness of group assertiveness training on the child participants’ social competence was also evaluated. Participants reported improved psychosocial functioning upon the conclusion of the workshop. Qualitative feedback from the parents highlighted the efficacy of an integrated approach, predicated on group psychoeducation and in-session interventions designed to improve parent-child communication. Clinical implications and directions for future research are provided. Keywords: Asian, psychological well-being, culture, parent-child relationship Acknowledgement: This project was supported by the W.K. Kellogg Foundation. We are extremely grateful to the Asian-American immigrant children and parents who participated in the workshops and provided invaluable input. Also we would like to thank Dibya Choudhuri, Ellen Koch, and Hsiao-Wen Lo, who provided expertise in the design and implementation phase of workshops, and Alethea Helbig, who provided editorial assistance with earlier drafts of the manuscript. Tsu-Yin Wu (the corresponding author) is a Professor in the School of Nursing, Eastern Michigan University, 328 Marshall, Ypsilanti, MI 48197. E-mail: twu@emich.edu JooHyun Lee is a clinical psychology doctoral candidate at Eastern Michigan University, 341 Science Complex, Ypsilanti, MI 48197. E-mail: jlee71@emich.edu mailto:twu@emich.edu mailto:jlee71@emich.edu International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 731 More immigrants move to the United States each year than to any other nation (Martin & Widgreen, 2002). In 2009, over 37 million foreign-born individuals were estimated to be living in the United States (U.S. Census Bureau, 2010), and immigration is thought to account for more than 40% of population growth in the nation (Rong & Preissle, 2009). Although considerable research has been devoted to examining the impact of immigration (e.g., Berry, 2001; Berry & Sam, 1997; Leu et al., 2008), most immigration research has historically focused on adults, with considerably less attention afforded to youths (Aronowitz, 1984; Berry & Sam, 1997). The significant and growing proportion of immigrant children in the United States (U.S. Census Bureau, 2000) has prompted a number of scholars to address this gap in the literature (e.g., Berry & Sam, 1997; Fuligni, 2001; Le & Stockdale, 2008; Rumbaut & Portes, 2001). The reduction of health disparities in immigrant and racial or ethnic minority children, who are often from immigrant families, has been a topic of growing interest to researchers and U.S. policy makers (Kataoka, Zhang, & Wells, 2002; Snowden, Masland, Libby, Wallace, & Fawley, 2008; Yeh et al., 2002). However, most existing research focuses on disparities in mental health among Hispanic and African-American children (Brach & Fraserirector, 2000; Huang, Caughy, Genevro, & Miller, 2005; Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2005), with far fewer studies focusing specifically on the Asian-American population (Huang, Calzada, Cheng, & Brotman, 2012). Popular characterizations of Asian-American children as a “model minority” (Yu & Vyas, 2009), underpinned by the group’s high rate of academic achievement (Schneider & Lee, 1990), may have inadvertently contributed to the scarcity by perpetuating the notion that Asian-American children are psychologically resilient despite the disadvantages associated with their migrant or ethnic minority status. This view is further perpetuated by documented lower rates of behavioral and health problems among this group (Kim & Chun, 1993; Nguyen et al., 2004; Yeh et al., 2002), but findings remain mixed with some studies reporting higher rates of internalizing disorders such as anxiety and depression within this population (Chang, Morrissey, & Koplewicz, 1995). Given that Asian Americans are one of the fastest growing ethnic groups in the nation, projected to comprise 8.2% of the total U.S. population by the year 2060 (U.S. Census Bureau, 2012), it is imperative that researchers better understand the discrepancies in published studies. Examining the few extant studies focusing on Asian-American children may shed some light on the mixed findings of past research. For example, Huang and colleagues’ (2012) secondary data analysis of the Early Childhood Longitudinal Study-Kindergarten Class (ECLS- K) found that Asian-American children had higher levels of internalizing disorders and lower levels of interpersonal relationship skills relative to white children. They also found that Asian- American children were less likely to be in good physical health when compared with white children, but this disparity was only evident among children of Asian immigrant parents and not in children of U.S.-born Asian parents. These findings suggest a within-group health disparity (U.S.-born vs. immigrant) among the Asian-American youths. Chan (2003) further stressed the importance of considering contextual factors when examining the Asian-American population. He argued that the “model minority” label is predicated on the assumption of homogeneity and International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 732 does not take into account the disparities between those who have been in the country for decades and recent migrants. The inherently disruptive nature of immigration may predispose Asian-American children to a wide range of psychological difficulties, including depression and anxiety (Padilla & Duran, 1995; Pumariega, Rothe, & Pumariega, 2005). The psychological difficulties may also be amplified by risk factors unique to ethnic minority groups, such as racial discrimination (Leong & Okazaki, 2009). Discrimination by peers can be particularly stressful given the importance of positive peer acceptance among this age group (Grossman & Liang, 2008; Yeh & Inose, 2002), and this may increase the risk of developing mental health problems. Indeed, Shrake and Rhee (2004) found that perceived discrimination was a significant positive predictor of both internalizing and externalizing disorders among young Korean Americans, and the prevalence of problem behaviors was strongly associated with the adolescents’ perceptions of racial discrimination. Intergenerational conflict is another construct that has received increased attention within the literature on Asian-American families (Park, Kim, Chiang, & Ju, 2010). Immigrant children adjust to a new culture at a faster pace than their parents (Birman & Trickett, 2001), and the resulting acculturation gap is believed to contribute to the development of parent-child conflict (Suárez-Orozco, 2001). That is, conflicting cultural orientations (e.g., interdependence vs. independence) may strain the parent-child relationship (Park et al., 2010), which, in turn, may lead to deleterious psychosocial outcomes such as delinquent behavior (Choi, He, & Harachi, 2008), poorer life satisfaction (Phinney & Ong, 2002), and depressive symptoms (Ying & Han, 2007). The relative de-emphasis on affectionate and open communication among Asian families (Le, Berenbaum, & Raghavan, 2002), largely rooted in the high value placed on maintaining harmony in Asian culture (Kim & Kim, 2001), may further aggravate these negative outcomes (Park, Vo, & Tsong, 2009). Our team previously conducted a focus-group pilot study of challenges and concerns related to racial discrimination and bullying among Asian-American immigrant families. The focus group findings confirmed that Asian-American children and adolescents (particularly those from immigrant families) often experienced racial discrimination and bullying by their peers. As an example, one participant reported that their son is often bullied by his classmates as he “eats stinky food.” Participants also confirmed the presence of parent-child conflict within their households. The conflict was described as a sense of alienation and estrangement that was attributed to generational and cultural differences. For instance, a Filipino parent described how disciplinary techniques may be a source of contention within immigrant households: I think one concrete example though of what could become a problem… you know, cultural values is one thing; but I think it’s the parenting styles that has gotten to be a little challenging. We were raised in the Philippines. I was whacked. I became okay. My dad used his belt, but I was okay. It was expected. It was part of my discipline growing up. The adolescents I see in our clinic, it’s a threat, what you are going to do, on the butt. … [They say] I’m going to call Child Protective Services, and that’s very difficult for someone who was raised in the Philippines. Their child was born in the Philippines, we bring them here, all of a sudden they are around people who are very into Child Protective Services stuff; that started to become such a problem. The balance has to be International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 733 there. I don’t know how you address it in schools but that’s a disparity in itself. The discipline that you were known to have and what is in American society today. Discussions with a Korean-American youth pastor revealed that this cultural gap may lead to the breakdown of communication between parents and their children: … so later on they realize there’s no point in me talking to my parents and they don’t talk to their parents. They talk to their friends. Their friends have the worst advice. Let’s do drugs. Let’s go party. Then they go into areas that I could consider depression or whatever and their school grades drop. Their parents get down on them. They don’t know what is going on. Their parents put them on ADHD meds or whatever meds. That’s kind of the story of most of them. The child and adolescent participants also reported perceived communication barriers with their parents. One Filipino participant remarked, “We had a problem with our parents’ tunnel vision like ‘our culture is the right way’ and that’s the only way.” Another Korean child participant concurred, “It was more like, they are never going to get it. My experience as a Korean American and the world that I was shown here in America was not the world that they were shown.” The current study aimed to address the above-documented challenges facing Asian- American families. Difficulties arising from the process of immigration and acculturation can be particularly challenging for children as they face the complex tasks of identity formation and cultural group affiliation (Suárez-Orozco & Qin, 2006) as well as negotiating any intergenerational conflict that may arise in their household. As such, the standard of care for psychological services must encompass both the risk and the protective processes relevant to the Asian-American population. To this end, we evaluated the efficacy of parent-child dyad workshops designed to promote effective parenting practices and self-regulatory skills. The interventions drew from several principles grounded in Asian parent-child relationships and relevant Asian or Asian-American mental health literature. First, in light of the conflict that often accompanies parenting in intercultural contexts (Park et al., 2010), the workshops provided parents with an opportunity to share their parenting experiences in small groups. This was implemented to develop a greater understanding of the common parental challenges in Asian- American households. Second, the workshops included brief psychoeducational programs, which were provided to both the parents and their children. This was done because culturally- influenced beliefs about the etiology of mental health and behavioral problems are often responsible for the observed racial or ethnic disparities in mental health service utilization by children (Yeh et al., 2005). Finally, given the effectiveness of social-skills training programs in reducing peer rejection among ethnic minority children (Lochman, Coie, Underwood, & Terry, 1993), child participants were provided with assertiveness training. Method Participants The current study used a convenience sample and the sampling was purposeful in that the selected cases met predetermined criteria of importance (Patton, 2001). The criteria for International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 734 participation included: (a) parents with an immigrant background; (b) parents who self-identified as being of Asian descent; and (c) consent from the parent-child dyads for their participation in workshops. Participants were recruited from flyers, recruitment ads in local ethnic newspapers, and word of mouth. Twelve dyads (child and parent) who identified their country of origin as being part of Asia attended the workshops. The analysis from subculture demographics revealed five Chinese (42%), three Japanese (25%), one South Korean (8%), one Vietnamese (8%), and one Taiwanese American (8%) family dyad. One parent-child dyad chose to identify as “other” (8%). Although the ratio of male to female child participants was equal, it was skewed in favor of females (58%) among the parents. The participant children’s ages ranged from 6 to 11 with a mean age of 7.8 (SD = 2.08). Four child participants were U.S.-born. The most common language spoken at home was Chinese (50%), followed by Japanese (25%), Korean (8%), Vietnamese (8%), and other (8%). Parents’ levels of education were: some college (9%), Bachelor’s degree (9%), Master’s degree (45%), and Doctoral degree (36%). Procedures The workshops, developed and implemented by an interdisciplinary team that consisted of professionals from psychology, counselling, social work, and nursing, were conducted from July 13, 2013 to August 17, 2013. However, due to various scheduling conflicts among the families, attendance was inconsistent. Informed consent and assent forms were provided to the parent-child dyads before the start of the study. Participants were told that the purpose of the study was to investigate the immigration experiences of Asian-American families in an effort to improve this population’s mental health literacy. They were informed that the study would involve attending presentations, engaging in small-group activities, and completing questionnaires. The voluntary nature of their participation was also acknowledged, and the parent-child dyads were informed that they might discontinue participation at any time. Participants were also told that the workshop sessions would be audio-recorded, and that the recordings, as well as their questionnaire responses, would remain confidential and only be used for research purposes. Potential language barrier issues were addressed by recruiting bilingual project staff versed in the participants’ native languages. Translated versions of the research instruments were provided. Parents were given a $25 gift card upon the conclusion of the project. The empowerment workshops were held in a local library in a Midwestern U.S. city; workshops were attended by immigrant or first-generation American children (age 6–11) and their parents. Pre-intervention and post-intervention outcomes were measured through both quantitative and qualitative evaluation forms completed by the parent-child dyads. The empowerment workshops consisted of four 90-minute weekly interventions. At the start of each session, parents and children split up into two groups to participate in a parent- or child-specific program. The two groups reconvened at a later time for a group discussion. The first week was devoted to introductions and providing the parents with the treatment rationale. Each of the remaining weeks included a brief psycho-education segment, followed by a session focusing on a different domain or skill (e.g., parent-child relationship building, assertiveness skills training, and anxiety management). International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 735 During the first workshop, participants completed the following pre-intervention measures: (a) demographics questionnaire (parents); (b) school performance measure (parents and children); and (c) Psychosocial Outcome Rating Scale (parents and children). The Revised Children’s Manifest Anxiety Scale-2 (child participants) was administered before the start of the second session. In week two, the workshop covered anxiety. In separate groups, the parents were provided with information on how to recognize anxiety in their children, and the child participants were provided with tools and tips for identifying the symptoms and signs of anxiety. Upon reconvening, a group facilitator provided brief didactic instructions to the parents on how best to approach the issue of anxiety (and other psychological difficulties) with their children. The third workshop revolved around assertiveness and social skills training. First, the parents and children were separated into two groups for about an hour. The parents disclosed their children’s reports of conflict and bullying in school. The group facilitators then shared ways that parents could help their children by modeling effective communication techniques to deter bullying. The children, in their workshop, first viewed a short clip depicting a challenging social situation. The group leaders then elicited suggestions on how one could defuse this situation. This was accomplished by implementing role-playing exercises to model assertive communication skills. The child participants also completed the Children’s Action Tendency Scale pre- and post- intervention to evaluate this workshop’s effectiveness. The fourth workshop focused primarily on improving parent-child relationships. Parents, in their group, first disclosed concerns about the potential barriers to a positive parent-child relationship. These barriers, in turn, were addressed by the group facilitators via brief psychoeducation segments (e.g., how anxiety may impact a child’s relationship with his or her caregivers) and role-playing exercises (e.g., encouraging parents to implement reflective listening skills). Child participants, likewise, were encouraged to disclose any concerns about their relationships with their parents. After the completion of these small group discussions, the parent-child dyads reconvened for a debriefing session. Each dyad then completed the post- intervention measure (Psychosocial Outcome Rating Scale). The parents received a $25 gift card for their participation in the study. Measures Demographic questionnaire. A demographic questionnaire was developed and distributed to the parent(s)/legal guardian(s) of the child participants. The measure included eight items assessing the following variables: (a) respondent’s relationship with child participant; (b) age; (c) level of education; (d) gender; (e) place of birth; (f) language spoken at home; (g) child participant’s age; (h) child participant’s gender; and (i) child participant’s birthplace. Psychosocial Outcome Rating Scale. An outcome rating scale was developed for this study. This four-item measure was distributed to both the parent(s)/legal guardian(s) and the child participants pre- and post- workshop. The measure was designed to provide a broad overview of the respondent’s general psychosocial functioning (personal well-being, social satisfaction, etc.). Ratings were provided on a visual-analogue scale and the format of the scale corresponded to participant characteristics. For child participants, the scale was anchored by a “sad” face (score of 0) and a “happy” face (score of 4). International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 736 Children’s Action Tendency Scale (CATS). The CATS (Deluty, 1979) is a 39-item self- report measure designed to assess assertive, aggressive, and submissive behavior in children. The instrument provides 13 vignettes of children in conflict situations. Each of the 13 situations is followed by three response alternatives presented in a paired-comparison format. For each of the pairs of alternatives the child is asked to select the one that best describes how he or she would behave. The number of aggressive, assertive, or submissive alternatives a respondent chooses constitutes his or her aggressiveness, assertiveness, and submissiveness scores, respectively. The paired comparison format allows for the assessment of the relative strength of each response against the other two. Scores on each dimension can range from 0 to 26. CATS’ reliability was demonstrated through its acceptable split-half reliability and test- retest values. The split-half reliability coefficients for the Aggressiveness, Assertiveness, and Submissiveness subscales were 0.77, 0.63, and 0.72, respectively (Deluty, 1979). Test-retest reliability over a four-month interval was 0.48, 0.60, and 0.57 for the Aggressiveness, Assertiveness, and Submissiveness scores (Deluty, 1979). The observed reliability estimates are rather modest but reflect the measure’s intent to assess state, as opposed to trait, tendencies. Concurrent validity was established through the measure’s significant correlation with a measure of self-esteem and peer and teacher rating of interpersonal behavior (Deluty, 1979). Furthermore, the scale is able to successfully discriminate between samples of clinically aggressive and normal children. Revised Children’s Manifest Anxiety Scale-2 (RCMAS-2). The RCMAS-2 (Gerard & Reynolds, 1999) is a 49-item measure that assesses the level and nature of anxiety in children and adolescents. In addition to providing a global level of anxiety symptoms, RCMAS also evaluates anxiety on three dimensions: (a) physiological anxiety; (b) worry or over-sensitivity; and (c) social anxiety. As well, the scale provides a validity scale (Defensiveness subscale) to control for social desirability biases. Participants respond to each item using a yes-no format, with higher scores indicating higher levels of the construct being assessed. Reliability was established on several fronts with generally acceptable psychometric properties (Gerard & Reynolds, 1999). School Performance Measure. A pre-screening measure was developed to evaluate the parent/legal guardian’s domains of concern with respect to his or her child’s academic functioning. This 7-item self-report measure was comprised of yes or no choices and open-ended questions. The items assessed the parent/legal guardian’s perception and observation of the child’s academic behavior and performance (e.g., “Has your child ever expressed any worry or concern with going to school? Provide examples.”) An alternative measure was developed for the child participants. This 9-item self-report measure comprised open-ended questions and a visual analogue scale, which used smiley faces as its two anchor points. The items assessed the child’s general view towards, as well as experiences in, the school setting (e.g., “How do you feel about school?”; “Tell us about the last time you felt sad at school.”) International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 737 Results All the data were entered by a trained research associate and double data entry was completed using the Statistical Package for the Social Sciences (SPSS-PASW- Version 18.0.3) to ensure the entered data were as correct and as clean as possible. Appropriate scales and subscales were computed prior to data analysis and statistical analyses were performed using the SPSS- PASW. Quantitative Analysis Means and standard deviations of the employed scales are presented in Tables 1, 2, and 3. Table 1 Comparison of Means (Standard Deviations) on Psychosocial Outcome Rating Scale: Parents & Children Subscale Session: Pre-test Session: Post-test M SD N M SD N t df p-value Parents Personal well- being 4.24 1.17 5 4.49 .44 6 -.53 9 .61 Family and close relationships 4.65 .22 5 4.27 .97 6 .85 9 .42 Work, school, and friendships 4.03 1.62 5 4.50 .48 7 -.74 10 .47 General sense of well-being 4.55 .29 5 4.06 .73 7 1.41 10 .19 Children Personal well- being 3.19 .90 7 3.56 .50 6 -.90 11 .39 Family and close relationships 3.11 .89 7 3.60 .43 6 -1.24 11 .24 Work, school, and friendships 2.85 .94 7 3.63 .40 6 -1.89 11 .09 General sense of well-being 3.11 .76 7 3.78 .32 6 -1.69 11 .12 The pre- and post-tests showed improved scores in all domains of psychosocial functioning (i.e., personal well-being; family and close relationships; work, school, and friendships; general sense of well-being) for both the child and parent participants (Table 1). The International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 738 children, on average, reported a low level of overall anxiety (M = 9.13, range = 0–21; Table 2). One participant, however, reported a clinically significant level of social anxiety (T-score = 60). Using CATS, paired-samples t-tests revealed no significant differences between the pre- and post-intervention conditions (Table 3). Interestingly, the mean self-report scores of both the assertiveness and aggressiveness subscales were elevated in the latter condition while the level of submissiveness was decreased. Table 2 Means, Standard Deviations, and Range for Revised Children’s Manifest Anxiety Scale (RCMAS) Scale M (SD) Range Total RCMAS Score 9.13 (8.15) 0.00-21.00 Physiological Anxiety Subscale 2.88 (1.81) 0.00-5.00 Worry Subscale 3.88 (3.91) 0.00-10.00 Social Subscale 2.38 (3.02) 0.00-8.00 Defensiveness Subscale 5.13 (2.36) 2.00-9.00 Table 3 Paired Samples T-tests Comparing Means of Children’s Action Tendency Scale (CATS) and Subscales Measure M (SD) Range t df p-value Time 1 Assertiveness Subscale 21.67 (3.51) 18-25 -1.00 2 .42 Time 2 Assertiveness Subscale 22.00 (3.61) 18-25 Time 1 Aggressiveness Subscale 3.33 (4.93) 0-9 -1.73 2 .23 Time 2 Aggressiveness Subscale 4.33 (4.16) 1-9 Time 1 Submissiveness Subscale 13.67 (2.51) 10-16 0.87 2 .48 Time 2 Submissiveness Subscale 12.67 (0.58) 12-17 Note. Time 1 = pre-workshop; Time 2 = post-workshop Qualitative Findings Open group discussions offered an opportunity for participants to share general concerns and comments relevant to their experiences in the U.S. Participants were also encouraged to International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 739 provide feedback regarding their time in the workshop. The three prevailing themes that emerged during these discussions were: (a) increased insight into parent-child relationships; (b) academic concerns; and (c) perceived benefits from workshop participation. Insights on parent-child relationships. The parents indicated that they gained increased insight into parent-child relationships from participating in the workshop. This included increased empathy for their children’s inner experiences as well as a greater appreciation for proactive communication skills. One parent, as an example, recounted that “listening” as opposed to “criticizing” resulted in greater openness and disclosure from their child. The parents also engaged in a discussion of the potential problems associated with the increasing intergenerational cultural gaps with their children. The difference in language mastery, in particular, was highlighted as a factor that aggravated this gap. One parent remarked: That is my big concern because if we move here, her English is not as good as we expected and her Chinese also is imperfect. I don’t know whether it makes sense for us to move here because we lose on both sides. Parents also reported ambivalence regarding their ability to successfully facilitate their children’s cross-cultural transition. This ambivalence, in part, was attributed to the stressors in their own environment. For example, one parent noted that the cumulative stresses associated with their workplace impeded their ability to communicate effectively with their child. Academic concerns. The open group discussion also revealed issues relevant to the children’s academic experience. Parent participants first acknowledged the difficulty with effectively monitoring their children’s academic progress. One parent explained that it was often hard to interpret the test results used in the U.S. educational system as he was “accustomed to the kind of tests in my country”. Other prevailing concerns revolved around a lack of parent-teacher communication. Lack of English fluency prevented some parents from attending school functions and being actively involved in their children’s academic careers. The issue of language competency also extended to the children. Several children remarked that they “do not talk as much” in classroom settings due to poor English proficiency. Perceived workshop efficacy. Both the parent and child participants were asked to reflect on their experiences participating in the workshop. The parents noted that the open-group discussions were particularly helpful as they normalized the hardships associated with parenting. They also expressed appreciation of the workshop segments that provided specific, tangible strategies to cope with stress and anxiety (e.g., relaxation exercises). Parent-child role-playing exercises, designed to promote effective communication techniques, were highlighted as beneficial as well. One participant remarked: She tell(s) me (a) lot of things happen but did not know what exactly happened, and I did not give her okay (and say) this is right, you did this right, you did this wrong, most times, criticizing….. (I applied) what I learned recently, so I tell her ‘tell me what happened’ so I – it works. She gradually tells me what happened. The workshop’s efficacy was also echoed by child participants. One child remarked on the utility of practising assertiveness and conflict resolution skills with the workshop leaders. General International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 740 emotion-regulation skills, ranging from anger management to stress reduction techniques, were deemed to be helpful as well. Discussion This study sought to evaluate the efficacy of parent-child dyad empowerment workshops for Asian-American immigrant families. Workshop content was guided by findings from a previous focus group pilot study, and from relevant bodies of literature, regarding risk and protective factors associated with the mental health disparity of Asian-American immigrant children; these include acculturative stress, mental health beliefs, intergenerational conflict, quality of parent-child relationship, interpersonal difficulties, and racial discrimination (Huang et al., 2012; Leong & Okazaki, 2009; Nguyen & Anderson, 2005; Park et al., 2010; Yeh & Inose, 2002; Yeh et al., 2005). Qualitative evaluation data demonstrated evidence of the workshops’ efficacy. In particular, the increased use of proactive communication skills (e.g., active listening) by parents with their children led to greater parent-child relationship satisfaction. A prominent theme that emerged from the parents’ post-evaluation was the importance of addressing intergenerational cultural gaps with their children. More specifically, several parents raised concerns that the cultural gap will widen as their children enter adolescence and young adulthood. They remarked on the utility of the workshop that provided strategies and information centered on this issue which they could apply later on. Similar findings were consistent with current literature that implicates intergenerational cultural gaps as a key contributor to parent-child conflicts (Choi et al., 2008; Kim, Chen, Li, Huang, & Moon, 2009; Tsai-Chae & Nagata, 2008). Lastly, several parent participants reported that one of the major benefits of their participation was decreased feelings of isolation after learning of other families who encountered problems similar to their own. Qualitative feedback from child participants also highlighted the workshops’ efficacy. For example, the child participants reported greater use of adaptive emotion regulation strategies as well as a greater understanding of an assertive communication style. The preliminary results from quantitative evaluation data highlighted the potential efficacy of culturally-informed interventions. For instance, both parent and child participants reported higher levels of satisfaction within a wide range of psychosocial domains (e.g., personal wellbeing, quality of family relationship, and academic or occupational functioning) upon the conclusion of the workshop. In addition, the effectiveness of intervention was demonstrated by an increase in child participants’ understanding and use of assertiveness skills following an assertiveness training module. However, the pre- and post-intervention differences on these measures were not statistically significant, perhaps due to the relatively small sample size. Nonetheless, the results are still promising and attest to the potential utility of these interventions in promoting proactive communicative behaviors. Interestingly, the current study observed a higher, albeit still non-significant, level of aggressiveness after the assertiveness workshop. This was an unexpected finding that may be due to the influence of cultural backgrounds on communication styles. For instance, assertiveness may be more likely to be confused with aggression among individuals whose culture places a premium on interpersonal harmony (Markus & Kitayama, 1991). International Journal of Child, Youth and Family Studies (2015) 6(4.1): 730–745 741 Lastly, the present study found a negligible level of anxiety within the child participants. A follow-up examination of the measure subscales, on the other hand, revealed that some children reported clinically significant levels of rumination and social anxiety. Thus, it is crucial that assessment of anxiety symptoms in children cover a wide range of domains. This issue may be particularly important for Asian-American children as they are at a greater risk for internalizing disorders and social anxiety when compared to white children (Huang et al., 2012). Limitations Although the current study offers some promising findings, certain methodological limitations warrant discussion. First, the study’s reliance on self-report measures is problematic. Although visual-analogue and translated scales were introduced to circumvent potential language competency issues, self-reports are still susceptible to numerous biases (e.g., social desirability). The generalizability of the results is further limited by the relatively small study sample and non- experimental study design and recruitment method. Type II error and the lack of a randomized controlled design limited this study’s ability to draw conclusive causal inferences about the employed interventions. Furthermore, participants were recruited through convenience sampling from local community organizations and through word-of-mouth. This may have resulted in a selection bias. Lastly, the sample was skewed to better-educated parents. This may have further limited the generalizability of the results to more diverse populations, including those that are less educated and are of low socioeconomic status. Implications and Future Research Our study contributes to the existing body of research addressing the health disparities among Asian-American immigrant children in a number of ways. Parental and child interventions, such as the one described in the study, are needed to address the unique stressors faced by immigrant families of Asian descent. Given that intergenerational cultural gaps were a prominent concern raised during the open group discussions, future studies and interventions may benefit from increased focus on this construct. For instance, assessing the parents’ and their children’s cultural orientation for any notable cultural gaps may be useful in developing a more comprehensive method of intervention. Extant research also suggests that children may acculturate at a faster rate than their parents (Buki, Ma, & Strom, 2003). As such, future studies should continue to evaluate the impact of this disparity in differing age groups with a larger sample size. Based on the findings of our study, health professionals may benefit from implementing interventions that encourage parental involvement in school settings. More specifically, strengthening parent-teacher communication in an effort to ensure that relevant issues are addressed in classroom settings may make the intercultural adjustment process easier for children. Moreover, it may be useful to work with educators and parents to help them recognize potential cultural differences in the symptoms of anxiety and other disorders among children. 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