The impact of life skills training on behavior problems in left-behind children in rural China: A pilot study

Abstract

A randomized controlled experimental pilot study was conducted in order to investigate the effect of life skills training on behavior problems in left-behind children (LBC) in rural China. Sixty-eight LBC were recruited from a middle school in rural China. The intervention group took a ten-week-long life skills training course. The Child Behavior Checklist (CBCL) and Teacher’s Report Form (TRF) were used to evaluate the behavioral problems of the children at three separate intervals: Prior to the intervention, the first week following the intervention, and three months after the intervention. Children in the intervention group showed significant improvement both in the CBCL and the TRF compared to children in the control group. Significant improvements were found in the CBCL total scores, internalizing behavior, externalizing behavior and seven subscales scores (p > 0.05). In TRF, similar significant improvements were found, except in internalizing behavior and the subscale of thought problems (p > 0.05). The effect of intervention remained the same three months after the intervention. As a pilot study, the life skill training was found to be effective in improving behavior problems in the LBC in rural China, with the exception of thought problems.

Keywords

Child behavior problems China left-behind children life skills training

Childhood behavior problems include being openly hostile, uncooperative and irritable on a regular basis, and displaying aggressiveness on occasion. All of these behaviors affect the social and daily living functions of children (Center of Knowledge on Healthy Child Development, 2007). If early interventions are not initiated, the social development and overall adaptation of children are negatively impacted. In severe cases these behavioral difficulties can be classified as being part of a mental health disorder (Herring et al., 2006; Merikangas et al., 2010). In rural China, there is a group of special children referred to as left-behind children (LBC). This term refers to children who are left behind in rural areas for at least six months by their parents, particularly when one or two parents migrate into cities for work (Fan, Su, Gill, & Birmaher, 2010).

Nowadays, millions of parents move annually from their villages to cities in hope of seeking better jobs and life opportunities, which helps to alleviate the labor shortage caused by the market economy in China. Since 1978, when the Chinese government implemented the opening-up strategy and initiated economic reforms, this kind of internal migration has been accelerating and currently remains at a high level (Wang et al., 2015). According to the Chinese sixth national census data in 2010 the number of LBC in the country are estimated to be 61,025,500, which accounts for 37.7% of children in rural China and 21.88% of all children in China (National Bureau of Statistics of China, 2011).

Researchers have shown that the family structure is closely tied to the behavioral development of the children in the family (Li, Yang, & Wang, 2005). Because of the long separation from one or both parents, in addition to the limited family education from grandparents, it has been reported that LBC exhibit a much higher rate of psychological behavior problems, up to 57.4%, compared to children who are not left behind (Xu, 2012; Xu, Tang, Wu, Xu, & Yang, 2007). Due to the lack of parental supervision and care, elevated rates of suicide and sexual abuse are reported in Chinese LBC (Zhou, Wang, & Hong, 2010). LBC demonstrated more anxiety, somatization, depression, hostility, tendency to fear, and life skill and social interaction problems (Gao, 2008; Zhou, Sun, Liu, & Zhou, 2005). School is an important place in terms of the social development of left-behind children. Previous studies reported that LBC showed positive attitudes towards their teachers and considered their teachers as important role models in terms of guiding them, expanding their knowledge, and helping to develop their character. An educator must play a central role in providing interventions to address the educational and social-emotional needs of LBC (Sun et al., 2015). However, very few intervention studies have been conducted for LBC in schools in rural china.

Life skills training is a term often used to describe learning experiences that aim to develop knowledge, attitudes, and especially skills (psychosocial competencies) that will enable learners to take positive actions towards developing and maintaining healthy behaviors, environments, and qualities of life (Botvin & Griffin, 2004). According to the World Health Organization (1999), life skills training is essential for the healthy development of children and adolescents and for preparing young people for their changing social circumstances (Marios, Irini, Aggeliki, & Steven, 2006). This training has been reported to reduce specific behaviors and multiple behavior disorders in children. It can be effective in helping to treat attention deficit hyperactivity disorder (ADHD), antisocial behavior, and drug abuse behavior effectively, as well as aiding in HIV prevention. It has been widely incorporated into the school education guidelines of some countries (Moshki, Hassanzade, & Taymoori, 2014; Pfiffner et al., 2007; Visser, 2005; Wang, Liu & Wang, 2007; Yankah & Aggleton, 2008). On the other hand, some studies report that life skills training may not be effective in changing all behavior problems, such as smoking (Luna-Adame, Carrasco-Giménez, & Rueda-Garcia, 2013).

In China, life skills traning is helpful in improving psychosocial competence and assists in the mental health development of middle school students (Sun et al., 2015). The high rate of behavior problems in rural LBC calls for early intervention. The purpose of this study is to investigate the effect of life skills training on behavior problems in left-behind children in rural China.

Methodology

Design

A random controlled experimental design was used.

Subjects

Subjects were recruited from a middle school in the Miluo county of Hunan Province, China. Subject recruitment was done from February 2012 to July 2012. Inclusion criteria: Third grade, had been left-behind by their parents for at least for six months; Exclusion criteria: Those who have other severe physical or mental diseases, or have received other interventions in the six months prior to the study.

After obtaining informed consent from each child and the primary caregiver, who was the single parent or grandparent, the children were randomly divided into an intervention group and a control group, according to the order of their school numbers. Students with odd numbers were assigned into the control group and students with even numbers were assigned into the intervention group. The grouping scheme was kept by the Local Youth Quality Education Bureau of Hunan Province, which was independent from this study. Primary caregivers and teachers who assessed outcomes were blinded to which group each child was in. The university and hospital ethical committees approved this study.

Intervention strategy

This study used the Williams Life Skills Training (WLST) as a basic guide, which included the training in ten different skills (Stauder, Williams, & Williams, 2006; Yankah & Aggleton, 2008). These were: Being aware, making a decision, deflection, problem solving, assertion, saying ‘No’, speaking up, listening, empathy, and increasing positives. Three well-known, nationally certified life-skill training experts, two who were child psychologists and one faculty member invited from another middle school, conducted the training. One expert focused on coping and mood control ability, one expert focused on being aware and interpersonal relationships, and the third expert focused on communication, creative skills, and critical thinking ability. Multiple teaching strategies were utilized in the intervention, including PowerPoint presentations, video watching, storytelling, scene simulation training, role-plays, and real case discussions. To reinforce the content of the training, students were given homework at the end of each training session. Experts wrote feedback and suggestions for each student and that feedback was given to students during the next session. Experts gave individual guidance and suggestions to students during the training sessions when necessary.

The training was conducted every weekend. There were ten training sessions over ten consecutive weekends. Each training session lasted about 60 ∼ 90 minutes. In each session, students were given small gifts such as pencils and erasers. All students in the intervention group finished ten training sessions. Students in the control group came to school at the first weekend, the third weekend, the sixth weekend and the tenth weekend to participate in fun activities of story telling, games, and video watching, which were not related to life skills training in the intervention group.

Measures

Demographic and left-behind characteristics included age, gender, family annual income, who the primary caregiver was, number of parents, immigration, and length of parental immigration. Demographic and left-behind characteristics were assessed before the intervention.

The Child Behavior Checklist (CBCL) and Teacher’s Report Form (TRF) were used to assess behavior problems of the children before the intervention, the first week after the intervention, and three months after the intervention. Students in intervention group and control group were assessed in the same time-period.

The CBCL is a parent or primary caregiver-report questionnaire that rates the child in terms of various behavioral and emotional problems (Achenbach, 1991; Achenbach & Rescorla, 2001). The TRF problem scale assesses the teachers’ reports of behavioral and emotional problems in the children. The CBCL and TRF largely contain the same items, but a few questions are different. For instance, only the CBCL has a question on nightmares, whereas only the TRF addresses the issue of sleeping in class. The CBCL has been one of the most widely used standardized measures for evaluating maladaptive behavioral and emotional problems in children aged 4- to 18-years-old. It was introduced in China in the 1980s and has been used with many Chinese children to evaluate their behavior problems. Good validity and reliability have been reported for both the CBCL and TRF (Jia, Wang, Shi, & Li, 2011; Leung et al., 2006).

On the basis of the 113 items, eight syndrome scales can be distinguished: (1) anxious/depressed; (2) withdrawn/depressed; (3) somatic complaints; (4) social problems; (5) thought problems; (6) attention problems; (7) rule breaking behavior; and (8) aggressive behavior. The sum of the first three subscales together forms the score for internalizing behavior; the sum of the last two subscales results in the score for externalizing behavior. Total scores are calculated by summing all items. The CBCL provides raw scores for each of the scales, computed by summing parent ratings (0 = ‘not true’; 1 = ‘somewhat true’; 2 = ‘often true’) for the individual items of each scale. Higher raw scores indicate adverse behavior. The response categories are equally weighted, such that a child could reach a score of 8 by having four items endorsed as ‘often true’ or eight items endorsed as ‘somewhat true’. The CBCL software uses individual scale and summary measure raw scores, or T-scores. Whether researchers should analyse CBCL raw scores or T-scores is a point of discussion in child development literature (Drotar, Stein, & Perrin, 1995). Raw scores have been used in multiple research studies (Roni et al., 2014; Thomas, Bo, Lars, & Tormod, 2012; Wang, Liu, & Wang, 2007). In this analysis, we reported the results using raw scores to detect subtle associations between life skills training and child behavior (Roni et al., 2014).

Statistical analysis

SPSS22.0 statistical software was used for data analysis. Descriptive statistics were used to describe the demographic characteristics. An χ² test and t-test were used to compare the differences of demographic and left-behind characteristics between the intervention group and control group. An independent t-test was used to compare the CBCL and TRF scores in the intervention group with the control group. A One-way repeated measure ANOVA was used to examine the scores (total score, internal behavior, external behavior and eight subscales scores) of CBCL and TRF at different time-points in the intervention group. An alpha level of 0.05 was utilized for this analysis. Results for model assumptions of normality, homogeneity of covariance, and linearity were satisfactory.

Results

Demographic characteristics

In the intervention group (34 children), 18 were male (53%) and 16 were female (47%), with the average age of 12.8-years-old. In the control group (34 children), 19 were male (55%) and 15 were female (45%) with the average age of 12.4-years-old. There was no significant statistical difference in gender and age. There were also no significant differences in family annual income between the two groups. Regarding left-behind characteristics, 20 (58.8%) had one-parent immigration and lived with the non-immigrating parent in the intervention group and 19 (55.9%) had one-parent immigration and lived with the non-immigrating parent in the intervention group. In the intervention group, eight children (23.5%) had less than one year of parental immigration, 13 (38.2%) had less than five years of parental immigration, and 13 (38.2%) had more than five years of parental immigration. There were no significant differences between the two groups in regards to primary caregiver and length of parental immigration. (Refer to Table 1, Supplemental Materials at the SPI/Sage website for the online version of this article for more detailed information.)

The Child Behavior Checklist

An independent t-test was used to examine the scores of CBCL between the intervention group and the control group at three different time-points. There was no significant difference (p > 0.05) between the intervention group and control group in the internalizing behavior (p = 0.581), externalizing behavior (p = 0.864), and total scores (p = 0.293) of the CBCL before the intervention. There were, however, statistically significant differences between the two groups in terms of internalizing behavior, externalizing behavior, and total scores of CBCL, both in the first week after the intervention (p ≤ 0.001) and three months after the intervention (p ≤ 0.001). A one-way repeated ANOVA showed that there were significant improvements in CBCL in terms of internalizing behavior (p < 0.001), externalizing behavior (p < 0.001), and total scores (p < 0.001) in the first week and three months after intervention, compared to before intervention (see Table 2 , Supplemental Materials). A post hoc test showed that there were no significant differences in CBCL scores between first week after intervention and three months after intervention (p > 0.05).

Specifically, the intervention group had significant improvements (p < 0.05) in the subscales of CBCL, including withdrawn, somatic complaints, anxiety/depression, social problems, attention problems, delinquent problems, and aggressive problems. There were no significant changes in thought problems (p = 0.494) in CBCL and minimal thought problems were identified before the intervention. After the intervention, both the CBCL subscale scores in first week after the intervention and CBCL subscale scores three months after the intervention were lower than the scores before the intervention (see Table 3 , Supplemental Materials). A post hoc test was also conducted and there was no significant difference between the subscales scores in the first week after the intervention and subscale scores at three months after the intervention (p > 0.05).

Teacher’s Report Form

There were statistically significant differences between the two groups in terms of externalizing behavior and total scores of TRF in the first week after the intervention and three months after the intervention (p < 0.05). However, there were no significant differences for internalizing behavior between the two groups in the first week after the intervention (p = 0.071). At three months after the intervention, significant differences for internalizing behavior were found (p < 0.001). A one-way repeated ANOVA showed that there were significant improvements in TRF internalizing behavior (p = 0.043), externalizing behavior (p < 0.001), and total scores total (p < 0.001) in the first week and three months after intervention, compared to before intervention (see Table 4 , Supplemental Materials).

Similar to CBCL, the intervention group had significant improvements (p < 0.05) in the subscales of TRF: Withdrawn, somatic complaints, anxiety/depression, social problems, attention problems, delinquent problems, aggressive problems both in the first week after the intervention and three months after the intervention. However, no significant improvement (p = 0.89) in thought problems was identified. The post hoc test showed that there were no significant differences in TRF subscale scores between the first week after intervention and three months after intervention ( Table 5 , Supplemental Materials).

Discussion

The demographic and left-behind characteristics of this sample were similar to previous research studies regarding the characteristics of LBC in China (Sun et al., 2015; Wang et al., 2015; Xu et al., 2007). Our data collection site, Muluo county, was one of the villages in China in which children were left-behind by their parents most frequently. There were 1304 students in this area and the number of left-behind children was as high as 928, 504 of which had both parents immigrate away from them (Ren, Wu, & Yue, 2010). Though a small sample size was used in the study, the sample was representative of the general LBC population in China.

The separation between parents and children in rural China has a significant effect on the behavior problems of these children. Previous literature has shown that between 27% to 57% of left-behind children in rural China exhibited problem behavior, depending on the different ages of the children and other measures (Huang & Li, 2007). The national normal in China is 12.97% (Xu, 2012). Though many studies have been conducted to examine the behavior problems in left-behind children in China (Gao, 2008; Xu, 2012; Xu et al., 2007; Zhou et al., 2005), very few intervention studies have been conducted and reported. As far as we know, this study was the first available pilot study to report the effectiveness of using life skills training to improve behavior problems in LBC in rural China. Our study contributed to the literature by identifying that LBC made significant improvements in almost all behavior problems after utilizing life skills training and that the effects of the training were maintained three months after the intervention.

This study used CBCL and TRF to evaluate the behavior problems of children. When parents or grandparents were able to supervise the specific behavior of their children at home, they proved to be the best observers of behavior ratings. They were, however, prone to either overestimate or underestimate behavioral difficulties (Angold & Costello, 2000). In the classroom, teachers could provide an evaluation based on comparison of other children in their classes (Angold & Costello, 2000).

In the intervention group, there was a significant improvement in CBCL scores. The findings were similar to those of previous studies (Liu & Wang, 2009; Wang et al., 2007) that applied life skills training to improving multiple behavior problems in children. The TRF results were similar to the CBCL results, with the exception of internalization issues. For TRF, there was no significant improvement in internalizing behavior in the intervention group compared to the control group. Previous research reported that children might display internalizing behavior in the presence of their parents or primary caregiver, but not their teachers (Stanger & Lewis, 1993).

Externalizing problems, such as discipline problems and aggressive behavior, may draw similar attention from both the primary caregiver and teachers (Stanger & Lewis, 1993). It remains unknown as to why our study found that the primary caregiver reported the changes of internalizing behavior but teachers did not. In addition, our study also found that there was no significant improvement in thought problem scores on the TRF scale, which might indicate the limited effect of life skills training on thought problems for rural LBC. Further research is needed to verify the results and explore possible explanations.

Better than originally expected, our study showed that there was significant improvement in almost all of the behavior problems in CBCL/TRF. Many reasons may be attributed to this. Firstly, the three experts in life skills training were very skilled and renowned in China, and were invited from big hospitals or schools from urban areas. Secondly, the intervention was carefully planned, conducted, and supervised by the researchers, some of whom were internationally well-known children psychologists or experienced school nurses. Thirdly, local teachers and staff in the rural middle school supported this research wholeheartedly. Every weekend, different teachers in schools volunteered to help to manage students. Our study showed a medium efficacy of maintenance after three months in the CBCL and TRF scores. With further research, life skills training with strict design and intervention might have more efficacy long-term.

Limitations

Several limitations are identified in this study. First, as a pilot study, it has a small sample size. In addition, this study only tracked the effect in short and medium-term follow-ups after the intervention. A study with a larger sample size and longer-term evaluation period (>12 months) is necessary in order to evaluate the long-term effect of life skills training. Second, as a pilot study, although we found there to be significant benefits of life skills training on behavior problems, it was costly to invite national experts from urban areas to participate in our study. It is important that future studies focus on training local teachers or psychology professionals on how to conduct life-skill training, followed by incorporating the possible effective training into the school curriculum in rural areas in order to decrease the cost of dealing with these problems. Third, this study did not measure the frequency of parental contact of LBC and education level of parents, both of which are potential factors related to the behavior problems in LBC (Sun et al., 2015). More complete left-behind characteristics should be assessed in further research. Fourth, all children in this study were around 12 years of age, so the findings might be specific to this period of early adolescence.

Conclusions/implications

Effective psychological and education practice in schools may serve as an important source of social support for LBC and may help with the significant behavior problems and mental health issues these children face everyday. Previous research has shown that the level of support from the teacher was the most important factor in predicting how lonely a left-behind child would feel. The teacher’s support was especially helpful for children experiencing just a little trouble (Liu, 2007). Our pilot study further indicated the significant benefits of life-skills training in schools. Given effectiveness may be compromised in real-world settings; we need to be very cautious about how to effectively translate the study into more practice. The effectiveness determined by our study was based on a strictly designed intervention and strong support from the local school system. We suggest that further intervention study on the life skills training of LBC is necessary in order to effectively manage behavior problems in LBC in the schools of rural China.

Supplemental Material

sj-pdf-1-spi-10.1177_0143034315618442 - Supplemental material for The impact of life skills training on behavior problems in left-behind children in rural China: A pilot study

Supplemental material, sj-pdf-1-spi-10.1177_0143034315618442 for The impact of life skills training on behavior problems in left-behind children in rural China: A pilot study by Jia Liu, Shan Liu, Jin Yan, Elizabeth Lee and Linda Mayes in School Psychology International

Supplemental Material

sj-pdf-2-spi-10.1177_0143034315618442 - Supplemental material for The impact of life skills training on behavior problems in left-behind children in rural China: A pilot study

Supplemental material, sj-pdf-2-spi-10.1177_0143034315618442 for The impact of life skills training on behavior problems in left-behind children in rural China: A pilot study by Jia Liu, Shan Liu, Jin Yan, Elizabeth Lee and Linda Mayes in School Psychology International

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors got funding support from Chia Fellowship at Yale-China Association.

Author biographies

Jia Liu is a Doctoral Student at Nursing School of Central South University and an Associate Professor at the Third Xiangya Hospital. Her research interests include child ‘left-behind’ in rural China, adolescent behavior and qualitative research.

Shan Liu is an Assistant Professor in Adelphi University College of Nursing and Public Health. Her research interests include psychotherapy, ‘left-behind’ children in rural China, psycho-oncology, chronic illness, and symptom management.

Jin Yan is a Professor at Nursing School of Central South University and the Vice Director of Nursing in the Third Xiangya Hospital. Her research interests include nursing management, mental health education, HIV/AIDS intervention and children behavion intervention.

Elizabeth Lee is an Assistant Professor in Adelphi University College of Nursing and Public Health. Her research interests include ‘left-behind’ children in rural China and psychotherapy.

Linda Mayes is an Arnold Gesell Professor in the Child Study Center and Professor of Epidemiology (Chronic Diseases), of Pediatrics and of Psychology of Yale University. Her research include Adolescent Psychiatry, Child Psychiatry, Chronic Disease, Electrophysiology, Epidemiology, Behavior, Addictive, Psychiatry and Psychology.

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Supplementary Material

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