Virtual care during the pandemic: Multi-family group sessions for Hong Kong Chinese families of adolescents with intellectual disabilities.

The suspension of social services in Hong Kong during the COVID-19 pandemic increased the caregiver strain for families of adolescent children with intellectual disabilities, possibly aggravating their family relationships. This article reports on an online Multi-Family Group (MFG) conducted during the pandemic for Hong Kong Chinese families of adolescents affected by mild-to-moderate intellectual disabilities. A thematic analysis of the experiences of the participating service users revealed three positive effects of the intervention model: improved family relationships, mutual helpful influences occurring among families, and a new understanding of family members with intellectual disabilities. The therapeutic group process used to promote family development is illustrated by a group vignette. The challenges and the practical considerations for conducting an MFG online are discussed.

Introduction

The COVID-19 pandemic has profoundly affected the provision of social services in Hong Kong. Reduced access to essential services has interrupted the daily routines of those who are socially vulnerable, namely people with intellectual disabilities. These sudden changes can create tremendous distress in family relationships. A recent study in the United Kingdom revealed that caregivers of children and adults with intellectual disabilities had significantly higher levels of stress than those in families with typically developing children, with the difference between the two groups being two to three times greater than that reported before the pandemic (Willner et al., 2020). Similarly, families of children and adolescents with special educational needs in Hong Kong, including those with intellectual disabilities, reported experiencing an increase in parental stress and the psychosocial problems of the children (Tso et al., 2020), suggesting there is a need to provide regular professional and social support for these families.

A research project aimed at developing a Multi-Family Group (MFG) model for Hong Kong Chinese families of adolescents with intellectual disabilities was launched in 2020 by the clinical-research team of a University in Hong Kong and a local self-help organization for parents of children with intellectual disabilities. The intervention was originally designed to be conducted face-to-face, but it was forced to change in light of the social-distancing measures adopted in Hong Kong after the outbreak of COVID-19. In order to maintain regular service provision, the clinical-research team developed an adapted model to be conducted online. This article describes this online model and reports the service users’ feedback together with a group-vignette analysis.

Literature review

The Hong Kong context

The general prevalence of intellectual disabilities among the world’s population is about 1%, and the highest incidence has been found among children and adolescents (Maulik et al., 2011). In Hong Kong, about seven in every thousand young people aged 15-24 were diagnosed with intellectual disabilities in 2015 (Commission on Youth, 2016).

There is a wide range of psychosocial services in Hong Kong that support the social integration of adolescents with mild or moderate intellectual disabilities. These services include vocational training, supported employment and community-based residential services. Some social enterprise projects run by non-government organizations operate restaurants and bakeries that provide on-the-job training and work opportunities for people with intellectual disabilities (Wong, 2019). In Hong Kong, psychoeducational programmes are the common services provided for parents and caregivers to increase their knowledge and skills for managing the emotional and behavioural problems of children with intellectual disabilities (Kim et al., 2003). However, the psychosocial services for people with intellectual disabilities in Hong Kong have been criticised for their individual basis and deficit orientation (Wong, 2019). There is a lack of family-based intervention in the systemic-developmental approach used in Hong Kong that attends to the developmental needs of adolescents with intellectual disabilities and their families.

The developmental challenges faced by adolescents with intellectual disabilities in Chinese societies

The transition into adulthood is the process of “moving from the protected life of a child to the autonomous and independent life of an adult”. This can be a challenging journey for both adolescents with intellectual disabilities and their families (Leonard et al., 2016: 1370). Young people with intellectual disabilities will need to go through different adjustments to their lives when they enter independent or semi-independent living and working environments (Wehman, 2006).

In the case of adolescents with intellectual disabilities in Chinese societies, parental support is crucial to their gaining confidence to explore their working environment autonomously (Xu et al., 2014). Although Chinese parents of children with intellectual disabilities were reported to be very supportive and responsible in caregiving (Li-Tsang et al., 2001), a study found that Chinese mothers of children with intellectual disabilities tend to encourage child autonomy less than mothers of typically developing children do (Su et al., 2017). Adolescents with intellectual disabilities in a Chinese society such as Hong Kong normally receive structured support from schools throughout their childhood and adolescence. Their parents may be less confident about their child’s ability to cope with the complicated social settings outside the school systems, and therefore may tend to withhold the freedom to make choices from their children even during their adolescence or adulthood. In addition, adolescents with intellectual disabilities were found to be highly vulnerable to be bullied by their peers in Chinese contexts (i.e., at the rate of 63% - 70%) (Chiu et al., 2017; Lung et al., 2019). Chinese parents of young people with intellectual disabilities may develop a high level of parental stress in regards to their child’s safety which prompt them taking proactive actions to avoid all forms of harm at all the times (Chang and McConkey, 2008). As a consequence, Chinese adolescents with intellectual disabilities may be deprived of the opportunities to explore the outside world that would otherwise be available to promote personal growth.

The Socio-cultural influences on Chinese families of people with intellectual disabilities in Chinese societies

The lack of social support was found to contribute to a high level of parenting stress among the parents, in particular the mothers, of children with intellectual disabilities (Chang and McConkey, 2008). In traditional Confucian Chinese culture, it is important to be a well-functioning person in society bringing honour to the family (Holroyd, 2003). Given these cultural beliefs, Chinese people may view intellectual disabilities as a disgrace to their family and the fault of the parents (Sue and Sue, 1987). Caregivers of children with intellectual disabilities in Chinese societies may feel shame and feel that disclosing the situation to others, including their extended family, would result in an increase in their caregiving strain, the affiliated stigma (Mak and Cheung, 2008), and tensions in family relationships (Chang and McConkey, 2008).

Chinese families of adolescents with Intellectual Disabilities during the COVID-19 pandemic

In general, studies in the west (e.g. Ferrer et al., 2017) and in Chinese contexts (e.g., Li-Tsang et al., 2001) showed that families of adolescents with intellectual disabilities have positive perceptions of their child’s situation and have high cohesion within the family. However, social services for adolescents with intellectual disabilities in Hong Kong have so far been greatly impacted during the COVID-19 pandemic, which may be posing a difficult situation for these adolescents and their families. A recent study in Hong Kong found that young people with special education needs, particularly those living in families with members with mental health problems and those in single-parent families, may be at risk of developing psychosocial problems with decreased social and emotional functioning and a deterioration of physical health during the pandemic (Tso et al., 2020). The sudden disruption of the daily routine and the prolonged restriction of activities at home may also increase the conflicts between young people with intellectual disabilities and their parents. Young people with intellectual disabilities may not be able to articulate their needs clearly, which may put great pressure on their parents during caregiving, and these families may end up in complete isolation at home during the pandemic (Yip, 2020).

The importance of using a strength-based approach in family intervention with Chinese families of adolescents with intellectual disabilities

With support from family members, and from members of the community such as other families encountering similar situations, Chinese parents with children with special needs can not only receive the help they need to reduce their caregiving anxiety under the pandemic (Ren et al., 2020), but also gain an experience of their own strengths in the caregiving situations (Li-Tsang et al., 2001), and be able to use their resilience to mediate their parenting stress (Zhao et al., 2021). In addition, strengthening the social support network and the sense of efficacy of Chinese parents of children with intellectual disabilities were found to be helpful to promoting parental warmth and support for their children’s autonomy (Su et al., 2017). Having a good relationship with parents and a supportive social network with peers were found to be the protective factors for those Chinese adolescents with intellectual disabilities who have experienced bullying due to their developing mental health problems (Chiu et al., 2017).

Studies in the west have demonstrated the positive outcomes of family-based interventions, such as family therapy, for families of members with intellectual disabilities (e.g. Rhodes, 2002; Wilkins et al., 2010), and in recent years, a growing body of western literature has put forward strength-based assessments and intervention for children and adolescents with intellectual disabilities (e.g. Carter et al, 2020) and for their families (e.g. Ferrer et al., 2017); however, there is a dearth of studies on family-based intervention using a strength-based approach in Chinese contexts and the provision of such kind of intervention during the COVID-19 pandemic. This study aims to document the implementation of an adapted Multi-Family Group for families of adolescents with intellectual disabilities in Hong Kong via an online communication platform, and report the feedback of the service users.

Multi-Family Group: the philosophy and its application

Multi-Family Group (hereafter referred to as the MFG) is the name given to a family-based intervention documented in Western countries (Asen et al., 2001) and in Hong Kong (removed citations 1 & 2). The MFG was developed to help families of patients with schizophrenia through improving their intra-and inter-familial communication and interactions (Laqueur, 1969). Unlike other traditional group therapies, the MFG facilitates changes in families via creating the experience of communality, instilling multiple perspectives, affording opportunities to learn from each other’s strengths, generating multiple possibilities and mobilizing multiple resources within the group context (Lemmens et al., 2009). The MFG emphasizes the co-creation of the therapeutic context by the group leaders and the participating families throughout the group process, which is characterized as a safe, supportive and empowering context that can cultivate mutual support, mutual understanding, active involvement and experiential learning (Asen and Scholz, 2010), reduce stigma, and increase social-network support within and between participating families (Lemmens et al., 2009). The study by Mactavish and Schleien (2000) evidenced the multiple benefits of family recreational activities for families of children with developmental disabilities. Szymanski and Kiernan (1983) conducted an MFG programme for families of adolescents with intellectual disabilities and demonstrated that positive outcomes, such as reducing the parent’s sense of loneliness while at the same time increasing their sense of community support, arose through the therapeutic process cultivated by the interactions and exchanges with other families in the groups.

Online family-based group intervention

Online group interventions began to emerge in the 1990s among a small group of practitioners (Murphy and Mitchell, 1998). Diverse approaches have been used, ranging from group therapy carried out in chatrooms or forums to e-mail conversations between group participants and a therapist (Chester and Glass, 2006). Previous literature has identified many advantageous features of online group intervention, including high accessibility, convenient use and sharing of website links, and the ability to conduct archival searches (Meier, 2004). A study of online support groups suggested that conducting groups online can be powerful in fostering personal empowerment through enhancement of the sense of control, feelings of independence and an increase in the frequency of social interactions (Barak et al., 2008). Although face-to-face conversations were found to have a more positive effect on the degree of satisfaction, perceived closeness and self-disclosure than online conversations, research findings suggested that online counselling could still achieve a conversational experience similar to face-to-face counseling if a longer time frame is allowed (Mallen et al., 2003).

Knowledge gaps

Although online group intervention has proliferated in recent decades, the literature on the use of online group interventions addresses only mutual-support groups, i.e., those focusing mainly on exchanges of information and emotional support (e.g., Bane et al., 2005). There is a dearth of knowledge of how online group intervention can activate therapeutic changes through the interactions among group participants. In addition, a majority of existing online group interventions are individual-based. Although family-based online interventions have been developed in Western countries (e.g., Wade et al., 2006), these were mainly conducted one-on-one (i.e., a therapist conducts intervention to one family at one time). There is little knowledge available concerning conducting online family-based interventions in a group format, especially in Chinese societies such as Hong Kong.

In light of this knowledge gap, the current study aims to answer two research questions: (1) Did the Chinese families of adolescents with intellectual disabilities who participated in the MFG feel satisfied with the online sessions as compared to the onsite sessions? (2) How did the parent-child relationships of the participating families change during an online family-based group intervention?

Method

Participants

All participating families were referred by a local self-help organization for the parents of children with intellectual disabilities. There were three criteria for recruitment: (1) the family has one adolescent child diagnosed with mild to moderate intellectual disabilities, (2) the family understands and speaks Cantonese (the local dialect) or Mandarin (the official language of mainland China), and (3) the participants are able to provide voluntary informed consent to participate in the intervention.

In all, six Chinese families of adolescents with intellectual disabilities participated in the MFG, including six adolescents with mild to moderate intellectual disabilities whose IQ scores were between 35 to 70 (three males and three females, mean age = 18.5), five fathers (mean age = 59.8), five mothers (mean age = 53.8), and one sister (age = 24). Among the six families, four were two-parent and two were single parent (one single mother, and one single father) families. The average monthly household income of the participating families was HK$27,667 (£2567.68) (Table 1).

Table 1.

Profile of the participating families.

Family no.	Gender of the adolescent with intellectual disabilities	Age				Education level				Monthly Household income	Level of Intellectual Disabilities	Other psychiatric diagnosis of the Adolescent with Intellectual Disabilities
		A^	F	M	S	A	F	M	S
1	Male	21	60	55	24	Senior Secondary	Junior Secondary	Junior Secondary	College	HK$24,000 (£2224)	Moderate	Autism Spectrum Disorder
2	Male	18	58	52	-	Senior Secondary	Senior Secondary	Junior Secondary	-	HK$35,000 (£3244)	Mild	-
3	Female	15	60	56	-	Junior Secondary	Senior Secondary	Senior Secondary	-	HK$16,000 (£1483)	Mild	Cleft lip and Cleft palate
4	Female	20	54	54	-	Senior Secondary	College	College	-	HK$40,000 (£3707)	Moderate	-
5	Male	19	-	57	-	Senior Secondary	-	Senior Secondary	-	HK$8,000 (£741)	Mild	Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder
6	Female	18	64	-	-	Senior Secondary	Senior Secondary	-	-	On social welfare subsidy	Mild	Autism Spectrum Disorder

^A = Adolescent; F = Father; M = Mother; S=Sibling (For example: “A1” refers to the adolescent with intellectual disabilities of the first family; “M4” refers to the mother of the fourth family).

Ethical considerations

This study was given ethical approval by the Committee of Survey and Behavioural Research Ethics of our University. All participants in the present study were informed of the ethical issues regarding the study, completed a written informed consent form before joining the MFG session, and took part on a voluntary basis. An agreement was made with the participating families at the beginning of the first session for maintaining confidentiality within the group, such as not to take photos of the other families. The participating families were free to withdraw from the study at any time without any penalty.

The Multi-Family Group sessions in onsite/online mode for Chinese families of adolescents with intellectual disabilities

The adapted model of the MFG for Chinese families of adolescents with intellectual disabilities aimed to (1) reduce parenting stress and enhance the parental efficacy of parents of Chinese adolescents with intellectual disabilities; (2) improve parent-child relationships; and (3) build up mutual-support networks among families of adolescents with intellectual disabilities.

Organization of the adapted MFG model

The implementation of social distancing in Hong Kong during the COVID-19 pandemic made it impossible to carry out a traditional MFG, which is usually conducted indoors and involves considerable physical interaction and experiential activities among the group participants. As indicated in Figure 1, the group structure of the MFG was modified in order to minimize the risk of COVID-19 infection during the group intervention. The duration of the intervention for each online MFG session was reduced to 2 h. Different strategies were adopted during the group sessions to maintain the attention of the participants, including doing stretching exercises to energize the group, using multisensory stimuli available on the internet (e.g., music and cartoons), and using the breakout room function to facilitate cross-family exchange.

Figure 1.

Modifications of the group structure of the MFG model for Chinese families of adolescents with intellectual disabilities under the COVID-19 pandemic.

Measure

Client Satisfaction Questionnaire – Parent version

The Client Satisfaction Questionnaire – Parent version (CSQ-P) is a self-administrated questionnaire, with a total of seven items, which was distributed to each participating parent after every onsite/online MFG session. The items address the perceived helpfulness of the group in fostering inter-familial understanding and support, in enhancing intra-familial understanding and support, and in providing a new understanding of the adolescent child’s developmental needs, as well as the degree of satisfaction with the group. All items were rated on a 5-point Likert scale, with possible responses ranging from 1 (strongly disagree/strongly dissatisfied) to 5 (strongly agree/strongly satisfied).

A Vignette on the MFG group process

A vignette about the changes in the interaction pattern of a parent-adolescent dyad in the MFG was developed to illustrate how the therapeutic process evolved throughout the onsite/online MFG sessions. As defined by Ely et al. (1997: 70), vignettes “encapsulate what the researcher finds through the fieldwork…and represent a growing sense of understanding about the meaning of the research work”. A snapshot vignette was adopted to document and to capture the essence of an observed experience (Spalding and Phillips, 2007). The vignette was developed based on the observations of the first author and was counter-checked by the rest of the clinical-research team members so that the representation of the experience could be validated against their observations of the same episode as it happened in the group session.

Post-treatment focus group

After the reunion session, two post-treatment focus groups were conducted. In order to hear from the adolescents with intellectual disabilities, they were assigned to a different group from their parents. Each group was led by a social worker with experience in leading an MFG together with a research assistant trained in psychology or a social-work postgraduate student. Following semi-structured interview guidelines, the interviewers explored the families’ experiences with participating in the onsite/online MFG and the perceived changes in themselves, their family members and their family relationships. Each focus-group interview lasted 45 to 60 min.

Data analysis

Quantitative analysis

The descriptive data (the mean score and the standard deviation) from the parent’s perceived helpfulness of the group and degree of satisfaction with the whole group session were calculated using SPSS. An overall mean score for the parent’s perceived helpfulness and degree of satisfaction with sessions conducted either in the onsite mode or the online mode was calculated by taking the average of the corresponding sessions (i.e., the onsite overall mean score was the average of the mean scores for sessions one to four; the online overall mean score was the average of the mean scores for sessions five to eight).

Qualitative analysis

The focus group interviews were recorded and transcribed verbatim. Pseudonyms were used to ensure confidentiality. Following the step-by-step guideline for a thematic analysis proposed by Braun and Clarke (2006), the authors first reviewed all of the data to become familiar with it, and then classified and organized the unstructured data into key themes, concepts and emergent categories (Table 2). All potential themes were checked against the dataset and the coded extracts. An ongoing analysis was performed to refine the naming of the themes until a clear definition was developed for each theme.

Table 2.

Data analysis of the qualitative data.

Theorizing Phase	Conceptual categories	Sub-theme
Improved family relationships	Changes in family interactions	More relaxed family atmosphere
		Increases in the mental spaces of the parents
		Active participation of the adolescents with intellectual disabilities
Mutual helpful influences occurring among the families	Exchanges	Participation of other families with a similar background
	Observations	Free expressions by the adolescents with intellectual disabilities
A new understanding of the family members with intellectual disabilities	Alternative intra-family experiences	A leading role played by the adolescents with intellectual disabilities

Results

Parents’ perceived helpfulness of onsite and online MFG sessions

As presented in Table 3, mean scores for the parents’ perceived helpfulness of the four onsite sessions and the four online sessions in three aspects, namely enhancing inter-familial understanding and support, enhancing intra-familial understanding and support, and providing a new understanding of the adolescent child’s developmental needs, were all above 4.00 out of 5.00. For the parents’ degree of satisfaction towards the group sessions, the mean scores for the four onsite sessions and the four online sessions were both above 4.50 out of 5.00.

Table 3.

Mean of ratings of parent’s perceived helpfulness of, and degree of satisfaction with, the onsite and online MFG sessions.

	Mean (s.d.)
	Onsite session	Online session
1. Enhancing inter-familial understanding and support	4.53 (0.42)	4.62 (0.40)
2. Enhancing intra-familial understanding and support	4.60 (0.41)	4.67 (0.44)
3. Providing a new understanding of the adolescent child’s developmental needs	4.39 (0.56)	4.59 (0.35)
4. Degree of satisfaction with the group sessions	4.66 (0.39)	4.57 (0.43)

A group vignette: the individuation process of an adolescent with intellectual disabilities and the letting-go process of the parent in the MFG sessions

In the third online session (the seventh of the eight MFG sessions), we conducted a parent sharing group while the adolescents were asked to prepare food for their families. In the parent sharing group, the parents discussed the topic of letting go and facilitating the independence of their adolescents with intellectual disabilities. F3 shared a recent incident with taking public transport, when he tried to let his daughter travel on her own. “My daughter requested she be allowed to travel in a separate car, but I forgot to alight from the train!” F3 shared his frustration at losing his daughter, and F6, whose daughter was 18 years old, echoed this frustration. “I have never been able to let go. I don’t feel safe letting her go to school by herself. The world is too dangerous. She likes to talk to strangers. I believe that she won’t get lost, but I just don’t feel safe about it.” The MFG leader then asked A6 if she wanted to be independent. “He should let me try,” she said clearly. “It is not okay to be with my father all the time. I will be in high school very soon.” After listening to the ups and downs of the letting-go experiences of other parents, A6 was encouraged.

At the end of the last MFG session, the adolescents were asked to set a goal for themselves. “I want to travel on the train by myself.” A6 said. “I tried yesterday. I travelled on my own to find my father. I really made it without asking anyone!” F6 said that he left home first and waited for A6 at the destination. “I told her to call me if she couldn’t find the way.” When F6 shared their new way of interaction, his daughter looked at him with a big smile on her face.

As illustrated by the group vignette, letting go so that an adolescent with intellectual disabilities can independently try something new is never easy for these parents. The online MFG session first provided a safe and trusted platform for the participating parents to share their worries and frustrations with facilitating (allowing) their adolescent children to start the individuation process; at the same time, it encouraged the adolescents to have autonomy and voice their wishes about growing up. With social support from other families with similar experiences, the parent-adolescent dyads started to explore a more developmentally appropriate way of interacting.

Positive effects on families

After experiencing the therapeutic group process of the MFG, the participating families perceived three positive changes, namely improved family relationships, mutual helpful influences occurring among the families, and a new understanding of the family members with intellectual disabilities.

Improved family relationships

Some participating parents (M1, M2, M4, F2 & F4) shared that, after joining the group, they experienced a positive change in the way their family members interacted when facing stressful situations in daily life, which in turn improved their relationships. As described in the group vignette, overfunctioning-underfunctioning is a common parent-adolescent interaction pattern in families of children with intellectual disabilities in a Chinese context. As adolescent children with intellectual disabilities may need a longer time to express their thoughts and feelings and some of them may be less able to do so, they may become emotional around their parents when their views are undermined or suppressed.

“My daughter could not express herself very clearly in the past, and whenever I failed to respond to her needs, she would be bad-tempered and we would always fall into quarrels quickly.” (M1, focus group 2)

The participating parents shared that their family life was often fully occupied by the training and caregiving tasks. In order for their families to survive under the tight daily schedule, they would hasten to finish all the tasks by helping to make the “best” choice for their adolescent children. The participating parents said that the group helped them slow down and be relaxed when they were with their adolescent children with intellectual disabilities and their other family members. Interacting at a slower pace gave an ample mental and psychological space for the family members to enjoy quality family time together, time during which they could nurture their family relationships.

“I was a very quick-tempered person. After joining this group, I found myself more relaxed when facing my son and other family members – the family atmosphere has become more relaxed, which in turn gives us space to nurture our family relationships.” (M4, focus group 1)

When the parents reacted to their adolescent children with intellectual disabilities at a slower pace, this created a space and time for their children to process the information and organize their thoughts. In the group sessions the parents said that they have developed a greater acceptance of letting their adolescent children take charge. The adolescents with intellectual disabilities became more relaxed and less reactive when interacting with their parents.

“Before joining this group, I was often trapped in the middle in mother-and-son conflicts at home…My wife now has a greater acceptance of our son after joining this group. My son feels less restricted by his mother here, and he has become less aggressive toward her. I feel more relaxed, too.” (F2, focus group 1)

The group context of the MFG was suffused with a relaxing atmosphere which helped slow down the speed with which the participating parents reacted to their adolescent children. A milieu for open communication was cultivated in the group, which helped promote understanding between the family members, and in turn, reduced the tensions between the parent and the child, improved the family atmosphere at home and induced a positive change in the family relationships.

Mutual helpful influences occurring among the families

According to the family participants, the occurrence of positive changes in family relationships took place because the group was suffused in a relaxing, secure and non-frightening atmosphere (M1, M2, M4 & F4). Creation of this therapeutic group atmosphere was said to be related to the high homogeneity of the backgrounds of the participating families, including the adolescent children being at the same developmental stage (F4) and the family relational situations being similar (M1 & M4). The atmosphere was also attributed to the participation of multiple families (A6, M1, M4, M2 & F6) and the volunteers in the group (M1, M2 & M4).

Sharing family problems with others is never easy in a Chinese society. The MFG created a safe and psychologically secure space wherein the participating parents and adolescent children could share their joy and worries in relating to their family members in an atmosphere of trust. The participation of other families with similar backgrounds did not only encourage the participating parents to lend support each other, but also encouraged the participating adolescent children with intellectual disabilities to express themselves in the group.

“My daughter was able to give a presentation about herself in front of so many people for 10 minutes. That was remarkable. I think my daughter was encouraged to try because she saw that someone of the same age as her had done it.” (M1, focus group 2)

The participating parents were amazed by the courage and the active participation shown by their adolescent children when they expressed themselves in front of a group of people whom they had only met a few times. A father highlighted the observation that giving the adolescents freedom to express themselves in the group sessions was the main difference between the MFG and the conventional services.

“The usual services we had received were mainly training-based – our children were involved only passively. It’s totally different here. [The group] allows them to express themselves freely… because they feel safe here.” (F4, focus group 1)

Because of the free expression exhibited by the adolescent children in the group sessions, the participating parents had opportunities to observe not only the changes in their own children, but also the way the parents and the adolescent children of other families interacted. These observations across their own and other families induced reflections on their parental practices.

“I can observe in the group and know about how the other parents get along with their adolescent children. I like to learn from the others by observation. I can borrow it directly if it works for my family.” (F3, focus group 1)

The MFG sessions provided a platform not only for the exchange of information, support and care between the participating families, but also a platform from which the participating group members could observe one another and reflect on their usual relational difficulties.

A new understanding of family members with intellectual disabilities

Apart from the supportive and secure group atmosphere, many of the participating family members were impressed by the design of the group activities –the adolescents with intellectual disabilities were often asked to play a leading role (M1, M2, M4 & F4), which offered them an alternative way to experience one another.

“In the blindfold activity, I was impressed to find that my son is a very careful person. It was the first time for me to be taken care of by him… I also discovered that my son can do something that is out of my expectation. [Interviewer: What was your new discovery about your son?) Confidence. I found that he has the courage to speak in front of others.” (M1, focus group 1)

In the blindfold activity, the adolescents with intellectual disabilities were asked to guide their parents, who were blindfolded, as they walked from one point to another without stepping on some obstacles. This experiential activity created a moment that reversed the usual roles between the parents and their adolescent children with intellectual disabilities, i.e., the parents had to rely on their children in this activity. The family participants said that the family activities, either the intra-familial or the inter-familial ones, had allowed them to observe their family members with intellectual disabilities from a new angle, which gave them a new understanding of the strengths of a person with intellectual disabilities (M1, M2, M4, S1), and induced a reflection on how they could relate to the family members with intellectual disabilities in a different way.

“I have seldom been involved in taking care of my brother. I’ve always questioned why I need to bear this responsibility… but now I’ve started to understand that my brother, in fact, is much more competent than I expected. I also figured out how to get along with him.” (S1, focus group 2)

Discussion

The results of the present study suggested the feasibility of conducting family-based group interventions online. The results of the descriptive statistical analysis suggested that the family participants seemed to be satisfied with the online MFG sessions and perceived them to be just as helpful as face-to-face sessions. Consistent with existing findings from the West (Callus et al., 2019; Hemm et al., 2018), parental overprotective care of the intellectually-challenged child regarding daily activities, such as the use of public transport, was also found in the participating families in the present study. Therapeutic changes in parent-adolescent interactions emerged during the group process of the online MFG, even without the therapist and families being in the same physical space.

The findings of the present study demonstrated that the adapted MFG model provided a helpful context for activating the individuation process of Chinese adolescents with intellectual disabilities. The social and communication challenges which serve as the diagnostic features of intellectual disabilities often make it difficult for the parents to recognize the strengths of their intellectually-challenged adolescent children, or for these young people to express their capabilities (Carter et al., 2015). The findings of this study suggest that the strength-based programme design of the adapted MFG model offered a secure and relaxing platform on which the adolescents with intellectual disabilities played a leading role in the activities (e.g., speaking up in front of the whole group to share their thoughts and views; leading their parents in a blindfold walk etc.), and together with the mutually supportive group milieu between the families, the parents of the young people with intellectual disabilities gradually altered their perception of the capabilities of their adolescent children. As illustrated by the participatory experience of the families in the present study, having a new understanding of the strengths and capabilities of their family members with intellectual disabilities stimulated reflections on their usual way of relating to their intellectually-challenged family members, and encouraged the exploration of a developmentally appropriate caregiving practice.

Recent literature has demonstrated the use of online interventions for engaging adolescents with diverse psychosocial needs shows promise (e.g. Craig et al., 2021; Sansom-Daly et al., 2019). Despite mobile phones and other devices often being restricted in the lives of adolescents with intellectual disabilities (Callus et al., 2019), the active participation of these adolescents in the group process described here may suggest the feasibility and acceptability of the use of a videoconferencing-based group intervention for Chinese adolescents with intellectual disabilities in Hong Kong. Future investigation is needed to explore the essential components of an online family group intervention that help engage and facilitate the active participation of adolescents with intellectual disabilities. The encouraging results of the evaluation and the group process suggest that conducting an MFG online is a promising alternative way to sustain professional and social support for Chinese families of adolescents with intellectual disabilities during the pandemic – and a good method to use in the future, if service provision is interrupted again. Given that the techniques used for leading and facilitating groups could differ substantially between online and face-to-face modes, our experience points to at least two practical considerations for conducting online family-based group interventions.

First, the development of a trustful therapist-client alliance in an online MFG is important for enabling cross-family interactions. Past literature on individual counselling in online settings suggests there is no significant difference between online and onsite counselling with regard to developing a therapeutic alliance (Simpson and Reid, 2014). However, as an MFG leader serves as the catalyst for the group process, face-to-face engagement with each of the families prior to the group meetings, including the pre-group interview, psychoeducational talk, and informal social interactions, could be helpful in establishing the rapport that helps to energize the group process.

Second, our experience suggests that a therapeutic group process can be facilitated even when the therapist and the families are not present in the same physical space, which is in line with previous findings (Sanders, 2019). Co-construction of knowledge and explicit discussion of experiences between therapists and clients have been identified as being more crucial than actual physical presence in activating the therapeutic process (Nobus and Quinn, 2005). The findings of this study extend the literature and suggest that, through the decentralization of the power of the group leaders as it is passed on to the family participants, inter-familial processes emerged during the process of group facilitation, which resulted in the co-construction of group knowledge and experience among all participants.

Despite these promising findings about the use of an online MFG for Chinese families of adolescents with intellectual disabilities, we did face some challenges. One was the method of group facilitation. In an online setting, the group process relies heavily on verbal/audible information, but gestures and facial expressions are also important. This requires extra attention when these types of non-verbal communication have to be seen on a screen (Weinberg, 2020). To address this, we alternated between the “gallery” and “speaker” views, which helped the leaders to observe the process within a family while at the same time seeing the process operate in the whole group. Using teamwork in the leading of an online family-based group is helpful for creating a more holistic picture of the whole group process.

Another challenge was how to foster interaction between participants. In a face-to-face MFG, inter-familial interactions can be easily promoted through activities. However, in an online setting, creating a friendly and autonomous group atmosphere was needed first to encourage cross-family connections. Self-disclosure related to the here-and-now (Weinberg, 2020), and open and non-hierarchical communication between group leaders, can shape the group culture and create an autonomous space for conversations.

Given the vivid psychosocial service needs of Chinese families of adolescents with intellectual disabilities during the pandemic, helping professionals should look for alternative ways to sustain existing services and adapt their interventions to the ever-changing environment. It is recommended that future studies develop the treatment protocol of this adapted MFG model further, and examine its treatment efficacy in supporting the development of families of adolescents with intellectual disabilities.

Limitations

This study has the following limitations. First, the findings of the present study are based on only one intervention group, with no comparison group. The results should be interpreted cautiously due to the presence of selection bias (Marsden and Torgerson, 2012). Second, the dual role of worker/investigator poses the risk of there being some social-desirability bias in the data collection and analysis. Triangulation was used to minimize the social-desirability bias, and carried out by adopting multiple data collection methods to study the same phenomenon (Jonsen and Jehn, 2009), that is the participatory experience of the families of adolescents with intellectual disabilities in the present MFG model. The measures to reduce the bias included the MFG leaders being absent during the collection of data through a self-administered client satisfaction questionnaire in order to remove the normative pressure on the participants (Grimm, 2010); the focus group interviews being conducted by interviewers who were not actively participating in the leading of the MFG, and had been trained prior to the interviews (Mooney et al., 2018); and the development of a vignette of the group process on the basis of the observations of a team of MFG leaders who reviewed and discussed the group process before and after every MFG session., Such participant observation has also been recommended as a strategy for triangulating other forms of data collection (Harvey, 2018).

Recommendations

The present study suggested the feasibility and acceptability of using online/onsite family-based group intervention to work with Chinese families of adolescents with intellectual disabilities in Hong Kong. However, further studies will be needed to investigate and develop the adapted MFG model. A qualitative study of the families’ subjective participatory experiences to explore the change mechanism of the therapeutic group would be helpful. The development and manualization of the protocol for the adapted MFG model would be helpful for promoting the application of the model in the social service sector; however, professional training and clinical supervision of the leading of the MFG would be needed. After that, rigorous studies using randomized control trials would be needed for efficacy testing.

Conclusion

The uncertain and fast-changing situations in the contemporary world have posed challenges for social service delivery. There is a pressing need to minimize the interruptions to the provision of services to vulnerable groups in the community. This type of adapted online MFG could be an alternative way of helping sustain professional and social support for Chinese families of adolescents with intellectual disabilities in Hong Kong during an extraordinary situation such as the COVID-19 pandemic.