Interventions for parents of children with NDD face two pivotal challenges. Firstly, many overlook the consequential influence of parenting stress, symptoms of parental anxiety and depression on the well-being of parent-child dyads. Though some address parenting stress, they fall short of considering comprehensive health outcomes. Secondly, current evidence has supported ACT as an empirically validated, transdiagnostic psychotherapeutic intervention for parents with dual benefits for the parent-child dyads, but the treatment delivery (e.g., group-based and guided online approaches) is primarily in-person, demanding the presence of expert personnel in every session, limiting its scalability and accessibility. Unlike other psychotherapies like CBT and mindfulness, conventional ACT sessions often adopt a 'one-size-fits-all' strategy, using standardised and pre-packed exercises lacking the personalisation necessary to address individual variations in psychological inflexibility.
Leveraging our available innovation, Pai.ACT, an AI-driven chatbot adopting the Focused ACT approach, seeks to offer personalised and scalable mental health solutions for Chinese-speaking parents of NDD children. With our encouraging preliminary data supporting our pre-trained NLP model's accuracy and Pai.ACT's feasibility, the investigators propose to examine Pai.ACT in a full-scale clinical trial. The study will examine the following research questions:
1. Is Pai.ACT more effective than positive parenting advice for reducing parenting stress (primary outcome for parents) of parents and the emotional and behavioural symptoms of their young children with NDD (primary outcome for children) over the 12-month post-intervention follow-up? 2. Is Pai.ACT more effective than positive parenting advice for reducing symptoms of depression and anxiety, improving parental psychological flexibility and parenting behaviour over the 12-month post-intervention follow-up? 3. Is Pai.ACT more effective than positive parenting advice for reducing the use of healthcare and rehabilitation services in children with NDD over the 12-month post-intervention follow-up? 4. What are the perceived benefits, satisfaction, strengths, and limitations of Pai.ACT from the parents' perspectives?
Primary caregivers who are Cantonese-speaking Hong Kong residents.
Parents aged ≥21 years.
Primary caregivers who adopt the responsibility of taking care of the child.
Living together with the child and having smartphone devices for daily access to the internet.
Parents diagnosed with severe mental illnesses.
Parents with learning, cognitive, language, communication impairments or other debilitating conditions. (e.g., hearing or vision impairment) that could impede full participation in the study)
Parents currently participating in /under the evaluation of other psychosocial, psychoeducation or parenting programmes.
Parallel
Pai.ACT
BehavioralThe Pai.ACT mobile app is an innovative therapeutic tool that utilizes Acceptance and Commitment Therapy (ACT). It integrates a sophisticated algorithm to analyze self-reported data and conversation texts when the user interacts with the AI chatbot and identifies what psychological inflexibility processes are required to be the most essential to be addressed for process-matched ACT interventions. These interventions, including self-help modules and experiential exercises, are enhanced with dynamic animations and audio metaphors (see NCT06086951). The contents of Pai.ACT is underpinned by: (i) the core principles of Focused ACT, (ii) our validated Focused ACT protocol used in our ongoing Focused ACT trial (see NCT05803252), and (iii) our validated ACT protocols, established since 2019, that address psychological challenges specific to the Chinese parenting context (e.g., affiliate stigma, internalisation of external criticism, self-blame) through a 4-to-6 week of ACT.
Positive parenting advice
Other interventionPositive parenting advice is recommended by the Child Assessment Services under the Department of Health, and videoconferencing session(s) led by another experienced counsellor for content revision. No access to AI chatbot/ACT modules will be granted.
Parenting Stress
Parenting stress will be evaluated utilising the Parenting Stress Index-Short Form (PSI-SF), comprising 36 items on a 5-point Likert scale. The PSI-SF assesses stress across three dimensions: parental distress, dysfunctional parent-child interaction, and challenging child behaviour, with a higher total score reflecting greater stress. The Chinese version of the PSI-SF has demonstrated robust convergent and discriminant validity, as well as internal consistency (α = .79-.88) in a Chinese parental cohort.
Child Emotional and Behavioural Symptoms
Child emotional and behavioural symptoms will be evaluated using the Strengths and Difficulties Questionnaire (SDQ), which consists of 25 items on a 3-point Likert scale. The SDQ, a parent-reported measure, assesses five domains: emotional symptoms, conduct issues, hyperactivity/inattention, peer-related problems, and prosocial behaviour, with a higher total score reflecting more symptoms. The Chinese version of the SDQ has shown satisfactory test-retest reliability (ICC = .75-.86) and discriminant validity among Hong Kong parents.
Symptoms of Depression and Anxiety
Symptoms of parental anxiety and depression will be assessed through the Generalised Anxiety Disorder-7 (GAD-7; 7-item, 4-point Likert scale) and the Patient Health Questionnaire-9 (PHQ-9; 9-item, 4-point Likert Scale), respectively, with high scores reflecting more severe symptoms. Both instruments have demonstrated adequate concurrent validities with other mental health measures (e.g., SF-12) and internal consistencies (α = 0.92 in GAD-7; 0.82 in PHQ-9) in HK samples.
Parental Psychological Flexibility
Parental psychological flexibility will be measured using the Psyflex questionnaire, a 6-item scale with a 5-point Likert scale. This instrument evaluates six dimensions of psychological flexibility: defusion, acceptance, present-moment contact, self-as-context, values, and committed action, The Psyflex has demonstrated excellent convergent and divergent validity, as well as reliability (Raykov's r = .91). Its Chinese version has been validated in the PI's work.
Parenting Behaviour
Parenting behaviour will be assessed using the Interpersonal Mindfulness in Parenting Scale (IM-P), a 23-item scale with a 5-point Likert scale. The IM-P assesses adaptive parenting behaviour across four dimensions: present-centred attention, emotional awareness, non-reactivity, and non-judgmental acceptance. The Chinese version of the IM-P has shown adequate convergent validity and internal consistency (α = .70-.84) among Hong Kong parents.
The use of health care and rehabilitation services
Utilisation of child healthcare and rehabilitation services, including the types and frequencies of services accessed from both private and public sectors over the preceding 12 months, will be assessed by parental reports and then crosschecked with the records provided by the Onsite Pre-school Rehabilitation Services teams.
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Chinese University of Hong Kong
Lead sponsor
Social Welfare Department, Hong Kong
Collaborator
Hong Kong Christian Service
Collaborator