A Mixed-Methods Study of Clinician Adaptations to Parent-Child Interaction Therapy – What about Culture?

Abstract

Parent-Child Interaction Therapy (PCIT) is an evidence-based practice (EBP) for young children with challenging behaviors. PCIT has been adapted to treat varying presentations and culturally diverse families. Although efforts have been made to disseminate PCIT into community settings, which often serve clinically complex, socio-culturally diverse, and marginalized communities, barriers to disseminating adapted models remain. An alternative strategy to understanding how to increase access to appropriately adapted PCIT is to learn from community clinicians’ practice-based adaptations to meet their clients’ diverse needs related to clinical presentation, culture, and language. This mixed-method study investigated community clinician adaptations of PCIT. Clinicians (N = 314) were recruited via PCIT listservs to complete a survey collecting background information, and adaptations to PCIT. Most clinicians had a master’s degree (72.1%), were licensed (74.2%), and were PCIT-certified (70.7%). Qualitative interviews were conducted with a purposeful sample of 23 community clinicians, who were 39% Spanish-speaking, were 30% Latinx, and 30% reported serving a ≥50% Latinx clientele. Clinicians reported engaging in adaptations aimed at augmenting PCIT more extensively than adaptations involving removing core components. Themes from qualitative interviews converged with quantitative findings, with clinicians most frequently describing augmenting adaptations, and highlighted reasons for adapting PCIT. Clinicians primarily augmented treatment to address clients’ clinical presentations. Clinicians rarely adapted treatment specifically for culture, but when mentioned, clinicians discussed tailoring idioms and phrases to match clients’ culture for Spanish-speaking clients. Implications for training PCIT clinicians in intervention adaptations will be discussed.

Parent-Child Interaction Therapy (PCIT) is an evidence-based parenting program that successfully reduces challenging behaviors among youth ages 2–7 years old (Lieneman et al., 2017). Notably, multiple efficacy studies have provided support for adapted PCIT protocols to treat diverse clinical presentations (e.g., anxiety-related behavioral challenges) and racially and ethnically diverse families, including Spanish-speaking Latinx families (Comer et al., 2018; Cotter et al., 2018; Hansen & Shillingsburg, 2016; Matos et al., 2009; Matos et al., 2006; McCabe et al., 2012). Though systematic cultural adaptations to the PCIT protocol for Mexican-American families were shown to be effective (McCabe et al., 2012; McCabe & Yeh, 2009), barriers to disseminating adapted protocols remain to meet the various cultural, clinical, and linguistic needs of families served within community mental health. However, the richness within variants of the Spanish language and the diversity of idioms used across Spanish-speaking regions likely contribute to difficulties in determining a single adapted model that would serve all Spanish-speaking clients. Additionally, within-group heterogeneity amongst Latinx families may necessitate individualized tailoring strategies. An alternative strategy to addressing increased access to culturally-appropriate PCIT and other evidence-based practices (EBPs) is to learn directly from community clinicians how they tailor these interventions to meet their racial and ethnically diverse clients’ needs (Ramos et al., 2021).

PCIT

PCIT has an extensive evidence base (Thomas et al., 2017; Ward et al., 2016) and employs the following empirically-supported strategies: 1) emphasizing the parent-child relationship, 2) using standardized assessments to inform treatment, and 3) using in vivo feedback (i.e., coaching) to help parents develop parenting skills. Treatment is provided in two phases: Child Directed Interaction (CDI) and Parent-Directed Interaction (PDI) (Herschell et al., 2002; Lieneman et al., 2017). During the CDI phase, parents learn the PRIDE skills, which include providing labeled (specific) praises for, reflecting, imitating, and describing appropriate child behaviors, and enjoying the parent-child interaction. Parents are also taught to selectively attend to appropriate child behaviors and ignore minor attention-seeking behaviors. PCIT therapists provide coaching in vivo to increase parents’ skill acquisition and to help parents apply the skills correctly. During the second phase, PDI, parents continue using these positive parenting skills in addition to learning and being coached to successfully implement discipline strategies (e.g., an effective and developmentally appropriate time-out sequence) as consequence for child misbehavior and non-compliance. Successful progress through PCIT is based on parental proficient use of skills and decrease in child disruptive problems; the PCIT protocol incorporates weekly administration of standardized assessments (e.g., parent report of child behaviors and behavior observations of parent-child interactions) to inform treatment and monitor progress.

Adaptations of PCIT

To address the greater diversity and complexity of clients seen for treatment outside of research trials, PCIT has been adapted to serve families in several ways. Adapted protocols and alterations in treatment format have been developed to address clinical comorbidities and different diagnostic presentations, to increase treatment accessibility, and to account for client cultural background (Lieneman et al., 2017; Niec, 2018). To extend the format of PCIT, protocols have been developed and tested for home-based PCIT (Gurwitch et al., 2020), internet-delivered PCIT (Comer et al., 2017), and group-based PCIT (Niec et al., 2005; Nieter et al., 2013).

PCIT Modifications to Address Comorbid Clinical Presentations

Given that child behavioral challenges often occur in complex clinical presentations (Park et al., 2018), modified PCIT has been tested in efficacy studies to address diverse behavioral and emotional difficulties, including mood and anxiety disorders (Carpenter et al., 2014; Puliafico et al., 2012). These modifications frequently include additional phases of treatment focused on skills that the parent and child need to address co-morbidities. For example, in PCIT-CALM, which addresses anxiety, parents are taught how to implement exposure within the Bravery Directed Interaction Phase (Comer et al., 2018). In an adaptation for selective mutism (PCIT-SM), the Parent-Directed Interaction phase of PCIT is substituted for a Verbal-Directed Interaction (VDI), which focuses on encouraging child verbalizations in new environments and with new people and uses a token economy to provide prizes and privileges to further encourage child verbalizations (Cotter et al., 2018). Additionally, PCIT has been modified for youth with neuroatypical development and related problems (Hansen & Shillingsburg, 2016). This adapted model maintained the positive parenting skills taught in standard PCIT but incorporated two modifications in line with intervention strategies for children with autism, including strategies on how to address limited verbalizations from the child and additional shaping to support compliance (Hansen & Shillingsburg, 2016).

Cultural Adaptations to PCIT

Culturally adapted PCIT models have also been developed and tested to fit the diverse cultural backgrounds of families (Baumann et al., 2015), including Mexican-American families (McCabe et al., 2012; McCabe et al., 2005; McCabe & Yeh, 2009). Particularly, Guindos a Niños Activos (GANA) is a culturally adapted form of PCIT that showed efficacy in reducing child externalizing symptoms for Mexican American families, and was even more effective than PCIT in reducing child internalizing symptoms (McCabe et al., 2012; McCabe et al., 2005; McCabe & Yeh, 2009). GANA aimed to increase the cultural fit of PCIT by re-framing the intervention to reduce stigma and shame, focusing more time on building rapport, including pictures and materials relevant to Latinx and Hispanic culture and demographics, and increasing clinician cultural responsiveness through additional cultural training. Adaptations incorporated in the GANA protocol intended to augment the delivery of PCIT for Mexican American families, while maintaining core components of the intervention.

Cultural adaptations of EBPs, such as the GANA program, have been informed by theoretical frameworks highlighting systematic adaptation processes, which delineate when and how to adapt and who should be involved in adaptation decisions (Baumann et al., 2015; Bernal et al., 1995; Domenech Rodríguez & Wielding, 2004; Lau, 2006). These models largely promote an augmentation approach to cultural adaptations. That is, they recommend adding components to treatment to make it more culturally relevant, for example, using relevant idioms or metaphors to frame interventions, addressing known risk factors for disorders in the target community, or lengthening the treatment to provide more opportunities to acquire skills that may be culturally unfamiliar (Bernal et al., 2009; Chu & Leino, 2017; Lau, 2006). Several meta-analyses reveal that culturally adapted interventions demonstrate moderate to large effect sizes on clinical outcomes (Benish et al., 2011; Cabral & Smith, 2011; Hall et al., 2016; Smith & Cabral, 2011; van Mourik et al., 2017). However, when adapted protocols are compared to original protocols, effect sizes are small or non-existent (Hall et al., 2016; Stirman et al., 2017). Lastly, creating adapted models to fit the characteristics of individual cultural groups would be impractical, given the diversity both between and within cultures and the changing nature of cultural norms, and has the potential to lead to stereotyping families based on cultural affiliation (Cabassa & Baumann, 2013; Stirman et al., 2017) rather than addressing aspects of the intervention relevant to individual families. Because community-based clinicians typically have culturally diverse caseloads with complex clinical presentations (Park et al., 2018), it is also possible that they are already employing ad hoc adaptations to address their client’s unique needs.

Adaptations within Community Implementation

Learning from therapists’ practice-based expertise delivering EBPs could further inform implementation and dissemination efforts (Chambers & Norton, 2016; Green, 2008). Consistent with an implementation science framework, adaptations to EBPs occur naturally when transported into the community (Barnett et al., 2018; Lau et al., 2017; Meza et al., 2019). Community clinicians may adapt interventions to meet clients’ needs or to improve client engagement (Gibbs et al., 2016; Ramos et al., 2021; Stirman et al., 2013). These adaptations are often driven by concerns regarding the relatively low number of racially and ethnically diverse populations represented in clinical trials of EBPs (Miranda et al., 2005). Furthermore, clients in community settings tend to be more clinically complex due to greater co-morbidity rates and greater exposure to trauma and poverty (Merikangas et al., 2010; Southam-Gerow et al., 2012). Additionally, community-based providers may share demographic traits, such as cultural, racial, or linguistic backgrounds, with clients, enabling them to adapt treatment by, for example, communicating in a client’s native language or integrating culturally familiar values and metaphors into treatment. Understanding how therapists adapt interventions for their culturally diverse and ethnically diverse clients is crucial to continue increasing access to culturally (including linguistically) sensitive interventions.

Improving mental health service for families speaking a language other than English (e.g., Spanish), is critical for several reasons. For instance, immigrant, Spanish-speaking individuals are more likely to encounter a greater number of barriers to accessing and utilizing mental health care, despite mental health service need (Bridges et al., 2012; Triplett, 2015). For instance, in a sample of adult immigrants, 39% met diagnostic criteria for at least one mental health disorder, and 31% identified the lack of services in Spanish as a primary barrier to accessing services (Bridges et al., 2012). When Spanish-speaking individuals do access services, the interventions are less likely to be evidence-based (U.S. Department of Health and Human Services, 2001). However, adding time to explain risk and protective factors, etiologies, and treatment options for child behavioral problems and incorporating time to address family stressors that may impact child behaviors were found to support treatment engagement among Puerto Rican families (Ramos et al., 2006). This finding indicates that although Latinx and Spanish-Speaking families have lower mental health utilization rates, and face additional barriers to treatment, clinicians can successfully increase treatment engagement by attending to client needs that may be socio-culturally specific. Understanding how Spanish-speaking clinicians adapt PCIT may be one strategy to understand how to increase the access of culturally appropriate, evidence-based services for Spanish-speaking children and caregivers.

EBP Adaptation Frameworks

Frameworks for studying EBP adaptations have been developed and are useful in investigating the process, nature, and outcomes of clinician-driven adaptations for Spanish-speaking families. Stirman et al. (2019) developed the Framework for Reporting Adaptations and Modifications-Expanded (FRAME), which helps implementation researchers examine adaptations and modifications of EBPs in a multifaceted and comprehensive manner. In their framework, Stirman et al. (2019) recommend focusing on both the process of adaptation and the reasons for adapting. In order to understand adaptation process, they suggest investigating when and how changes were made, whether changes were planned or unplanned, who determined changes needed to occur, the content/nature of changes, and whether changes remained fidelity-consistent. Efforts have also been made to understand and classify the content/ nature of clinician driven modifications or adaptations. For instance, Lau et al. (2017) reported findings from a system-wide reform of children’s community mental health services to understand how therapists adapt multiple EBPs; their findings indicated that community therapists engage in two types of adaptations: 1) Augmenting adaptations, which entail making additions to EBPs (e.g., tailoring presentation of strategies, integrating supplemental content, and lengthening the treatment or slowing the pacing); 2) Reducing/Reordering adaptations, which entail disengagement from some elements or structure of the original practice (e.g., omitting components, reordering components, or shortening the treatment or quickening the pacing).

In a study of community implementation of multiple EBPs with a predominately Latinx client population, Lau et al. (2017) found that Latinx therapists appeared to make more extensive Augmenting adaptations than Non-Latinx, White therapists. Barnett et al. (2018) expanded on these findings with qualitative interviews and found that clinicians reported engaging primarily in augmenting adaptations that tailored the language, terminology, and presentation to frame interventions, lengthened or extended the pacing of interventions, and integrated supplemental content into interventions. It has been suggested that community clinicians may adapt EBPs to meet the needs of their culturally diverse clients (Lyon et al., 2014), but more research is needed to determine whether community clinicians make adaptations to EBPs for their ethnically diverse clients that are consistent with those that have been found in adaptation research.

Lau et al. (2017) recommended that implementation support should encourage collaborative approaches that allow clinicians to share practice-based adaptations they have devised with other clinicians and with EBP developers. Within this framework, and despite the fact that PCIT has demonstrated effectiveness in community settings, with predominately Latinx families (Timmer et al., 2016), clinician driven adaptations to PCIT have not been investigated. Guided by the FRAME (Stirman et al., 2019), the current study aimed to investigate the following questions regarding PCIT implementation: 1) What adaptations to PCIT do clinicians make? 2) What considerations about a client’s clinical presentation and/or culture drive adaptations to PCIT? 3) Specifically, how do clinicians who serve Spanish-speaking families adapt the protocol?

Method

Participants

Of the 324 clinicians who met study criteria to be trained in and currently delivering PCIT, 314 reported on adaptations and were included in the final quantitative sample. Clinicians were on average 37 years old (SD = 8.52). The majority of clinicians identified as Non-Latinx, White (73.8%). Thirty-five percent of clinicians reported that the majority of their caseload were ethnically diverse clients, and 62.5% reported that least a quarter of their caseload were ethnically diverse clients. Most clinicians had a master’s degree (72.1%), were licensed (79.3%), and were PCIT-certified (70.7%). Twenty percent of clinicians reported speaking another language in addition to English, the majority of who indicated they spoke Spanish (18.5%). On average, clinicians had 22 clients in their total caseload (SD = 32.6), 8 PCIT clients (SD = 5.0), had been practicing for 8.8 years (SD = 7.0), worked 35.7 hours (SD = 11.5) at their agency, and had been trained in PCIT for 5.24 years (SD = 5.0).

Qualitative interviews were completed with a subset of 23 participants (87% female, 69.65% non-Hispanic White), 9 of whom identified that they were Spanish speaking on the survey. Interviewees were selected by a mixed purposeful sampling strategy, in which purposeful random sampling was combined with criterion-i sampling to ensure that the providers worked in community settings (Palinkas et al. 2015; Patton, 2002). Clinicians providing services in more than one language were oversampled to ensure adequate representation of therapists serving diverse clients. Qualitative results regarding PCIT adaptations in general (e.g., including cultural adaptations) focused on responses from all 23 clinicians. Table 1 showcases demographics and other clinician characteristics in greater detail.

Table 1.

Demographic and Professional Characteristics of Survey and Survey + Interview Sample

	Survey Sample	Interview Sample
Demographics
Age, M (SD; range)	37.02 (8.57; 22–71)	37.30 (6.68; 29–59)
N (%) Female	287 (91.4%)	20 (87%)
Race/ Ethnicity	n (%)
Non-Hispanic White	232 (74.4%)	16 (70%)
Latinx/Hispanic	45 (14.4%)	7 (30%)
Other Ethnicity	35 (11.2%)	0 (0%)
Race	n (%)
White	259 (85.2%)	22 (95.7%) (1 missing)
Black/African American	8 (2.6%)	0
Asian American/Pacific Islander	9 (3.0%)	0
American Indian/Alaska Native	2 (.7%)	0
Multiracial/ Not Listed	26 (5.6%)	0
Professional Characteristics
Language of service provision	n (%)
English only	245 (78.0%)	11 (47.8%)
Spanish	58 (18.5)	9 (39.1%)
Other	11 (3.5%)	3 (13%)
Professional Discipline	n (%)
Clinical Psychology	107 (34.2%)	8 (34.8%)
Social Work	69 (22.0%)	5 (21.7%)
Counseling	64 (20.4%)	3 (13%)
Marriage Family Therapy	63 (20.1%)	5 (21.7%)
Not Listed	10 (3.3%)	2 (8.7%)
Highest Degree Obtained	n (%)
Master’s degree	217 (69.3)	16 (69.6%)
Doctoral degree	86 (27.5)	7 (30.4%)
Other	10 (3.2%)	0
N (%) who are licensed clinicians	248 (79.0%)	22 (95.7%)
N (%) PCIT Certified Therapist	222 (70.7%)	20 (87%)
Years Trained in PCIT M (SD; range)	5.28 (5.00; 0–37)	5.35 (3.43; 1–13)
Years as therapist M (SD; range)	8.86 (7.00; 0–45)	8.30 (4.24; 2–22)
Current Caseload Characteristics
Current PCIT caseload M (SD; range)	5.69 (4.87; 0 – 30)	6.26 (3.85; 1 – 13)
Current Total caseload M (SD; range)	20.64 (18.44; 1–100)	19.17 (12.80; 3 – 50)
N (%) Clinicians with ≥ 50% Latinx Caseloads	70 (22.3)	7 (30.4)

Note. PCIT = Parent-Child Interaction Therapy. Clinicians in the Other category reported speaking other languages in addition to English, which including Chinese Mandarin, American Sign Language, Japanese, Polish, Portuguese, Russian, Chamorro, Vietnamese, and German.

Procedure

This study was part of a larger study investigating clinicians’ experiences implementing PCIT. Online surveys were created using Qualtrics and sent to the two main listservs of PCIT clinicians managed by PCIT International and the University of California Davis PCIT Training Center. Using strategies that have led to successful data collection with community therapists from email recruitment (Lau & Brookman-Frazee, 2016), participants received $20 gift certificates for completing the survey, which took 20–30 minutes on average. The survey asked whether participants would be willing to participate in a supplemental interview. Interview participants received an additional $40 gift card for participation in an hour-long interview about their experiences implementing PCIT, and specific to this study, the adaptations they made. Interviews were conducted by four graduate student researchers with expertise in providing PCIT and implementation science.

Of the 324 who completed the survey, 180 participants indicated that they would be willing to be interviewed (56%). Ten pilot interviews were conducted with early survey respondents to refine the interview protocol and were not included in the final interview sample. To ensure an interview sample representative of community service provision, individuals providing services in university training clinics (n = 19, 11%) were not included in the final interview sample, and those who also provided services in languages other than English (n = 37, 21%) were oversampled. Survey respondents who indicated that they worked in a community setting were divided into two groups, those who provide services in English only and those who provide services in any additional languages. Invitations were sent to participants from each group selected using an online random sample generator. Forty-three participants initially received interview invitations via email, and those who did not respond were sent a reminder email. Throughout the qualitative data collection phase, the research team discussed interview content and emerging themes during weekly meetings. Meeting discussions were annotated and transcribed to serve as an archive of recurrent content and emerging patterns. The qualitative research team determined that interview content became redundant after 23 interviews, indicating that saturation had been reached and recruitment, including follow-up emails to individuals who had not responded to the initial email invitations ended.

Measures

Demographics and clinician characteristics.

The Therapist Background Questionnaire (Brookman-Frazee et al., 2012) was administered to collect information on the personal and professional characteristics of clinicians. Demographic variables included: age, gender, and race/ethnicity. Professional background variables included: licensure status, mental health discipline, and highest degree obtained (i.e., Bachelor’s, Master’s, Doctorate). Workload variables included: number of hours in direct service per week and the number of clients in caseload. Additional questions inquired about PCIT certification status (e.g., in training, certified, certified as a trainer), years of experience with PCIT, number of PCIT clients, and estimates of total PCIT clients seen (e.g., 0–2, 2–6, 6–20, 20+).

PCIT Adaptations.

The Adaptations to Evidence-Based Practices Scale (AES; Lau et al., 2017) was used to assess the types of adaptations clinicians engage in. The AES contained six items, using a 5-point Likert scale (0 = not at all, 4 = a very great extent), asking the degree to which clinicians made specific adaptations to EBPs. Sample items included: “I integrate supplemental content or strategies when I deliver PCIT,” “I remove/skip components of PCIT,” and “I adjust the order of PCIT.” The developers of the measure conducted a factor analysis revealing two factor structures: Augmentation adaptations (3 items) and Reducing/Reordering adaptations (3 items). The original measure showed great reliability (ω = .95 - .98). The version in the current study showed adequate reliability for the augmenting adaptations subscale (ω = .72) but not the reducing adaptations subscale ω = .49). Short scales (e.g., <10 items) tend to have lower reliability scores (Ziegler et al., 2014).

Semi-structured interview.

A semi-structured interview guide asked clinicians questions to better understand the context in which adaptations were made and specifically asked about adaptations related to the Spanish delivery of PCIT. Sample questions included: Have you ever seen clients or have examples of families where you have had to tailor PCIT? Why do you make these adaptations? Do you ever adapt for culture? Clinicians who self-identified as Spanish speaking, were also asked specific questions regarding whether they adapt for language. Prompting interview questions included: How do you modify PCIT for Spanish-speaking families? What are the reasons for you to modify PCIT for Spanish-Speaking families?

Data Analytic Plan

Mixed-Methods Design.

This study used a QUAN + QUAL approach with simultaneous data collection and equal weighting of data in analyses (Palinkas et al., 2011). Quantitative data were collected to gain a breadth of understanding about the extent to which clinicians made different types of adaptations and predictors of these adaptations. Qualitative interviews were conducted to gain a depth of understanding about the content, reasons for adapting, and impact of cultural and linguistic considerations when adapting PCIT.

Quantitative Data Analysis.

A paired-sampled t-test was conducted to determine whether clinicians engaged in Augmenting adaptations differently than Reducing/Reordering adaptations. Separate multiple regression analyses were conducted to investigate clinician characteristics that predicted clinician engagement in both Augmenting and Reducing/Reordering adaptations. All quantitative analyses were conducted with SPSS v27 software.

Qualitative Data Analysis.

The research team transcribed, audited, and entered all interviews into NVivo v13, a software that aids the coding, organization, and retrieval of codes. A priori codes, informed by two implementation science adaptation frameworks, were developed. Stirman et al.’s (2019) Framework for Reporting Adaptations and Modifications – Expanded (FRAME) provided a framework for analyzing the process and reasons for adapting and modifying evidence-based treatments. In the current study, process codes were related to content and nature (e.g., tailoring, adding elements) of adaptations and modifications, which were further informed by Lau et al.’s (2017) Augmenting and Reducing/Reordering adaptations. Codes related to reasons for adapting included cultural background, diagnoses and clinical presentations and preferred language. Consistent with the APA Style Journal Article Reporting Standards regarding qualitative research being iterative versus linear (Levitt et al., 2018), an iterative process was used where the preliminary codebook was first applied to a sample text to ensure all relevant themes were captured, emergent codes were added, a priori codes were revised, and coding discrepancies were resolved as needed following consensus meetings by the research teach. A final codebook, with definitions of each code, was developed collaboratively by the entire research team. Table 2 provides a list of all codes and definitions used.

Table 2.

Codebook of Adaptation Content and Reasons for Adapting

Codes	Definitions
Adaptation Types
Removing/skipping	Removing or skipping elements of the intervention.
Shortening/condensing	Reducing the pacing/timing of the intervention; for example, limiting the number of sessions, coaching for less time.
Reordering	Changing the order of intervention modules or segments.
Lengthening/extending	Extending the pacing/timing of the intervention; for example, repeating sessions, purposeful addition of specific PCIT sessions.
Integrating/adding	Adding another treatment into PCIT, integrating other techniques into a general PCIT approach (including evidence-based adaptations such as BDI, emotion coaching, etc.), adding elements to PCIT.
Tailoring/tweaking/refining	A change to the intervention that leaves all of the major intervention principles and techniques intact (e.g., modifying language, creating somewhat different versions of handouts or homework assignments, cultural adaptations).
Changes in packaging or materials	Alterations in the materials used: for example, changing the toys used.
Substituting	Substituting one element of PCIT for another.
Spreading	Breaking up session content over multiple sessions.
Loosening structure	Departing from the intervention (“drift”) followed by a return to protocol within the encounter; drift from protocol without returning; adding extra sessions (e.g., check-in with parents only, collateral sessions) that replace or delay PCIT.
Reasons for Adapting
Race/ethnicity	Clinician references to clients’ race or ethnicity.
Gender identity/sexual orientation	Clinician references to clients’ gender identity or sexual orientation.
Socioeconomic status or access to resources	Clinician references to clients’ socioeconomic status or access to resources.
Developmental level	Clinician references to clients’ developmental level (e.g., age, cognitive capacity).
Physical ability or characteristics	Clinician references to clients’ physical ability or characteristics.
Literacy and educational level	Clinician references to clients’ literacy and education level.
First/spoken language	Clinician references to clients’ first or spoken language.
Legal status	Clinician references to clients’ legal status (e.g., CPS involvement, custody, court-mandates).
Immigration status	Clinician references to clients’ immigration status.
Cultural or religious norms	Clinician references to clients’ cultural or religious norms.
Clinical diagnoses or presentations	Includes behavioral issues, symptomatology, diagnoses, trauma histories, or other client or parent related factors impacting treatment, including general stress level.
Crisis or emergent circumstances	Clinician references to specific events and circumstances that impact clients’ engagement in treatment.
Motivation and readiness	How motivated or ready a family, parent, or child is for treatment.
Sociopolitical	Existing laws, existing mandates, existing policies, existing regulations. Political climate, funding policies, historical context, societal/cultural norms, funding, or resource allocation/availability.

Note. This codebook was informed by the FRAME Coding Manual (Stirman et al., 2019).

Two undergraduate coders coded all 23 interviews, with 50% of them coded by an advanced coder (1st or 2nd author). Advanced coders met at intervals with the coding team to review and resolve coding discrepancies and consulted with the entire research team as needed to finalize the coding process. Qualitative data were analyzed using a thematic analysis approach, which has been commonly used in psychotherapy research (Braun & Clarke, 2006) and implementation research (National Institute of Health, 2019). Thematic analysis seeks to highlight shared meaning and contrasts – in essence to extract ‘stories’ told through interview responses (Clarke & Braun, 2018). Themes were created through analyzing the co-occurrence of content and reason codes; for example, adaptations to augment the delivery of PCIT and preferred language. Themes were finalized through consultation and collaboration among all research team members. The research team included a doctoral level clinical psychologist/ faculty member, two doctoral students, and two undergraduate students. The faculty member is a certified trainer in PCIT. Both graduate students conducting the interviews and overseeing data analysis, have worked in community mental health, and provided PCIT services, and the lead of this study on cultural adaptations identifies as a Mexican, English-Spanish bilingual Clinical Psychology doctoral candidate. All interviews were conducted in English.

Integration of Quantitative and Qualitative Findings.

The functions of this QUAN+QUAL mixed-method design were (1) Convergence – triangulating both sets of results to answer the same question and determine if both generated similar conclusions, (2) Complementarity –with qualitative narratives providing depth of understanding (e.g., how therapists made content adaptations) and quantitative findings to provide breadth of understanding (e.g., what types of adaptations are made most frequently across a wide range of PCIT therapists), and (3) Expansion – using qualitative results to further explain the reasons for the adaptations reported in the quantitative findings (Palinkas et al., 2011).

Results

Quantitative results

Clinician adaptations to PCIT.

A paired-samples t-test was conducted to investigate whether clinicians engaged in Augmenting adaptations differently than Reducing/Reordering adaptations. Results suggested clinicians engaged in Augmenting adaptations more extensively (M = 2.33, SD = 0.81) than Reducing/Reordering adaptations (M = 1.31, SD = 0.41), t (314) = 25.20, p < .001). Notably, with the 0 to 4 scale, on average, clinicians reported very limited Reducing/ Reordering adaptations and moderate Augmenting adaptations.

Predictors of clinician adaptations.

Clinicians’ ability to provide PCIT in a language other than English was related to clinicians’ engagement in Reducing/Reordering adaptations (R² = .07, b = 0.19, SE = 0.08, p = .017) but not Augmenting adaptations (R² = .03, b = 0.26, SE = 0.16, p = .097). Clinicians who reported speaking English and another language (88% Spanish) reported engaging in more Reducing/Reordering adaptations (M = 1.46, SD = 0.50) than clinicians who reported speaking English only (M = 1.27, SD = 0.37). No other predictors were significant for either Augmenting or Reducing/Reordering adaptations (see Table 3).

Table 3.

Multiple Regression Results of Augmenting and Reducing/Reordering Adaptations on Clinician Characteristics.

	Augmenting			Reducing/Reordering
Effects	B	t	p	B	t	p
Years as therapist	0.03	0.49	.624	−0.05	−1.85	.065
Total caseload	0.10	0.78	.438	0.09	1.34	.181
PCIT Caseload	0.28	1.71	.089	0.10	1.31	.190
Years PCIT trained	−0.09	−0.55	.581	0.02	0.49	.631
Hispanic Ethnicity (Yes vs No)	0.09	0.51	.607	0.02	0.29	.775
Language (English vs Spanish + Other)	0.26	1.66	.097	0.19	2.40	.017

Note. PCIT = Parent-Child Interaction Therapy. Clinicians in the Spanish + Other category were primarily bilingual in English and Spanish (88%).

Qualitative results

Augmenting and Reducing/Reordering adaptations.

Clinician responses to semi-structured interviews converged with quantitative findings suggesting that therapists were limited in their adaptations of PCIT, with multiple therapists highlighting the importance of maintaining fidelity to the protocol (e.g., “I pretty much stick to the, the protocol for PCIT. I don’t stray too often from it).” Furthermore, consistent with the quantitative findings, when clinicians discussed adapting the PCIT protocol, they were more likely to describe engagement in adaptations to augment the delivery of PCIT than adaptations to reduce or reorder PCIT components.

Qualitative themes regarding augmenting adaptations also complimented and expanded on the quantitative findings, providing rich examples of how clinicians modified the protocol and their reasons for doing so. Overall, augmenting adaptations centered around utilizing previously adapted and tested PCIT protocols for clinical diagnoses, incorporating other evidence-based practices or strategies into PCIT, and tailoring PCIT delivery to fit individual families’ circumstances. One clinician stated,”…we do a lot of PCIT CALM where I work, so that’s like a particular adaptation because we get a lot of kids that have really severe anxiety, and so like, understanding the function of the behavior, we can make some specific adaptations to PCIT.”

Clinicians reported PCIT adaptations involving integrating or adding other treatments/strategies into PCIT primarily in response to families’ clinical diagnoses or presentation, and developmental level. For example, one clinician described how they address trauma in PCIT:

“I take the elements of TF-CBT, the essential components of TF-CBT and the essential components of PCIT and in CDI, I do trauma-ed[ucation] with the family together, and then I will do a teach session, a CDI teach, and then each CDI coach session I introduce a different emotion regulation skill that the parent models for the child in the session, and then if the child mimics that, I’m coaching the parent to praise the child and I’ll coach the parent to do a lot of the things I’ll do with kids in TF-CBT, so a lot of the time it’s outside, there are skills that are not PRIDE skills that I am using, but the end result is worth it.”

Though clinicians rarely discussed reducing or reordering components of the PCIT protocol, when they did, it was primarily in response to the child’s or parent’s clinical diagnoses or presentation or emergent life evens within the family:

“I seem to have a lot of issues with needing to skip DPICS with couples that are in crisis, you know, mom comes in or dad comes in and they’ve been fighting the past week with their spouse, they’re emotionally fragile in those moments and have a hard time focusing in on play because they don’t know whether or not they’re gonna get divorced the next day.”

Culturally Relevant Adaptations.

Overall, clinician responses suggested a minimal number of adaptations due to cultural factors (e.g., “I was very aware of our cultural differences, but I can’t think of how I, I don’t know. I can’t think of like how I modified my practice in response to them”). Another clinician shared making “modifications to the way I talk, but not any real modifications to the protocol.” More specifically, this clinician described leaning on one family’s religious beliefs to help explain the importance of the structure in CDI stating, “Jewish philosophers who talk about the parent as almost a, what’s the word for it, like a frame, like a lattice, and the vines kind of grow based on that structure, and you gotta put up the lattice, right, in order for the vines to grow in the direction that you need. Talking about PCIT like that, it’s like yes, the goal is to change your child’s behavior, but it’s not always about spare the rod, spoil the child, instead it’s about creating that structure.”

Adaptations with Spanish-speaking families.

Supporting this study’s research question concerning Spanish delivery of PCIT, clinician responses suggested specific adaptations or approaches clinicians make when delivering PCIT to Spanish-speaking families. In contrast to quantitative findings revealing no differences in Augmenting adaptations based on therapist language, qualitative themes expanded on these findings suggesting that clinicians providing PCIT to Spanish speaking families primarily tailored the language used in the protocol.

“So for example, praising, that is the concept that is sometimes unfamiliar to some Spanish-speaking families, and so not only do we try to gauge what word, or words they use for praising, but we may also just use a phrase that means praising. One that I’m thinking of specifically is that, I was coaching the parent to say ‘echale porras’, and that means, throw cheers, literally at the child, and it’s kind of like what a cheerleader does, and that seemed to stick with the parent better than praise. It seemed to be more meaningful for the parent to be a cheerleader. Another example I can think of is, for enthusiasm, in Spanish I have used the phrase ‘ponerle crema a los tacos’, put sour cream on your tacos, which is in, at least in Mexico, it’s a very extra thing to do and so that’s how I might communicate to parents. You have to be really extra, you have to be…very enthusiastic, but without necessarily using that word. So, we’ve changed some of the language as well.”

In addition, clinicians described engaging in tailoring the presentation of PCIT materials and pacing of teaching strategies primarily in response to Spanish-speaking caregiver’s literacy levels. As one clinician stated:

“… for the Spanish-speaking, sometimes I feel like it’s too much information, they haven’t been in school in a long time, so they’re not used to getting so much information, so breaking it down, role-playing, coming up with some exercises, coming up with some short cuts, like the flash cards have been helpful, they’ll take them home, they can bring them into session. We do more of that kind of stuff with them. We also often have parents that have challenges with literacy, particularly our Spanish speaking families, our Latino families, and for those we tend to use a lot of visual materials. For example, we have our standard sheet that explains the PRIDE skills and then we have one that we created here at [agency] that just has pictures on it and less text and so we tend to use that one when families present with some literacy challenges.”

Consistent with quantitative findings suggesting Spanish-speaking clinicians were more likely to engage in reducing adaptations than English-speaking clinicians, Spanish-speaking clinicians discussed skipping certain PCIT components (i.e., parent report of child behaviors) primarily in response to Spanish-speaking caregivers’ literacy levels. For example, a clinician stated, “30 or 40% of the Spanish speakers on my caseload don’t read well enough to fill it [ECBI] and then doing it orally is extremely time consuming.”

Discussion

In the literature, it has been recognized that adaptation of EBPs may be inevitable for successful implementation outside of controlled research settings (Barnett et al., 2018; Lau et al., 2017; Meza et al., 2019). While PCIT has demonstrated effectiveness with racial and ethnically diverse families, including Spanish-speaking Latinx families (Matos et al., 2009; Matos et al., 2006; McCabe et al., 2012), additional efforts may be necessary to increase the accessibility and acceptability of PCIT for Spanish-speaking Latinx families. Guided by the FRAME, this study sought to understand practice-based adaptations clinicians make to the content of PCIT and reasons for doing so. Specifically, efforts were made to understand if adaptations were made for Spanish-speaking families to increase engagement in the treatment.

The current findings suggested that clinicians engaged in minimal to moderate adaptations that sought to augment the treatment to fit clients, as revealed by quantitative and expanded upon by qualitative results. These findings suggest that clinicians delivering PCIT to community-based families were likely retaining good fidelity to the standard treatment model. This is promising given that treatment fidelity is crucial for ensuring delivery of effective and high-quality interventions (Hukkelberg & Ogden, 2013; Marques et al., 2019), especially when there is a strong evidence base such as in the case of PCIT. The fact that PCIT clinicians reported limited adaptations could indicate that the standard protocol is viewed as adequately flexible for a range of client clinical and cultural presentations. However, it may also suggest that clinicians are not taking sociocultural considerations into account in their provision of PCIT and may not be trained to adapt treatment for ethnically diverse families.

Using the FRAME to capture how therapists adapted the content of PCIT along with the reasons for these adaptations, helped to illuminate that minimal adaptations were made due to the client’s culture. Given our efforts to include clinicians that served Spanish-speaking Latinx clients and specific attention to culture in our interview guide, it is surprising that more cultural adaptations were not reported. Nevertheless, the limited number of cultural adaptations reported among clinicians was consistent with previous findings on culturally relevant adaptations in other EBPs. For instance, Barnett et al. (2018) reported on a qualitative study including a predominantly Latinx sample of clinicians (61%) delivering various EBPs to predominately Latinx children and families. In their study, Barnett et al. (2018) found that clinician adaptations to EBPs were primarily driven by child and family characteristics including clinical presentations and emergent life events, but not culture. This, along with the current findings, further points to the relevance of further investigating how the lack of culturally responsive adaptations to EBPs impact treatment outcomes in children’s mental health services.

The findings in our study pertaining to Spanish-delivery of PCIT suggest that clinicians primarily tailor the language and presentation of PCIT for their Spanish-speaking clients. The clinicians in our study reported tailoring the language used to explain PCIT concepts, such as labeled praises (a positive parenting skill to praise specific, positive, parent-approved child behaviors such as being respectful) to match idioms or phrases that Spanish-speaking parents used. While none of the clinicians pointed it out, these findings were consistent with systematic changes made to PCIT through the GANA program, a PCIT protocol adapted for Mexican-American families (McCabe et al., 2012; McCabe & Yeh, 2009). GANA used tailoring of materials and content by re-framing the intervention to reduce stigma and shame, focusing more time on building rapport, and including pictures and materials relevant to Latinx families. Additionally, the primary goal of GANA was to increase the cultural fit of PCIT for Mexican families, therefore, the program placed heavy emphasis on increasing clinician cultural responsiveness through additional cultural training. The clinicians in our study did not discuss more extensive adaptations to address cultural factors, even when prompted by interviewers, beyond delivering PCIT in the families’ language of preference (i.e., Spanish) and utilizing idioms or phrases relevant for families.

One factor that may further influence the emphasis on language may be related to that fact that, as a manualized treatment, PCIT has materials in Spanish available to clinicians. In previous studies, however, community clinicians have noted that translated materials are not always adequate or appropriate for the clients they serve (Regan et al., 2017). This issue becomes more complex given the richness and variability within the Spanish language across diverse Spanish-speaking groups; for example, the GANA program used porras to describe praise while the standard Spanish protocol refers to praise as elogios; both can convey the same concept but may have varying levels of familiarity and cultural appropriateness depending on the country of origin for a family. The diversity in the Spanish language may be driving clinicians’ tailoring efforts towards utilizing wording that families find relevant and appropriate. This further speaks to the need to potentially personalize treatment for individual families. McCabe and Yeh (2020) describe the development of a personalizing instrument to increase accessibility and engagement of families from diverse cultural backgrounds in PCIT. Their personalizing instrument utilizes a cultural assessment approach to inform treatment and yield tools clinicians can use based on parents’ treatment expectancies, etiological explanations, endorsement of parenting styles incompatible with PCIT, and family support for treatment. This is important because it could increase the focus on cultural assessment in addition to clinical assessments that are commonly seen in the adaptation of EBPs.

Whereas clinicians did not report many cultural adaptations, they did report modifying treatment for other reasons outlined in the FRAME, including child or parent diagnoses or clinical presentations. Adaptations reported included adding other interventions or strategies to PCIT. These results are consistent with previous studies on adaptations of EBPs in community-based settings. Dyson et al. (2019) found that clinicians delivering an intervention to reduce challenging behaviors in children with Autism Spectrum Disorder modified the language to explain behavioral concepts to make them more accessible to parents, slowed the pace of the intervention, integrated other treatment elements, attempted to involve other family members in treatment to support engagement, and helped parents identify challenging behaviors and their functions, all to improve treatment outcomes. Similar to the current findings, Dyson et al (2019) also reported that clinician reasons for adapting were to address clients’ clinical presentation, needs, and functioning. Adapting EBPs to address clients’ diagnoses and clinical needs may not be surprising when considering that EBPs, including PCIT, have been expanded into adapted protocols that address a variety of specific diagnoses such as developmental delays (Hansen & Shillingsburg, 2016), selective mutism (Cotter et al., 2018), mood and anxiety disorders (Carpenter et al., 2014; Puliafico et al., 2012). It could be that these adapted models to address diverse clinical presentations have been more widely disseminated and implemented than those for different cultural groups.

Strengths and Limitations

The mixed-method approach utilized in the current study allowed for a large sample size to obtain both breadth and depth of information to understand clinician engagement in adaptations to PCIT. This study also focused on clinicians’ on-the-ground and practice-based adaptations as an alternative approach to inform potential implementation efforts of EBPs. Additionally, the inclusion of both English and Spanish speaking clinicians and efforts to explore culturally responsive adaptations in the study may help advance knowledge and efforts to continue increasing access to quality mental health services for traditionally underserved populations.

These findings should be considered within the limitations of the study. The cross-sectional nature of data collection allowed for analysis of correlational associations but not cause and effect relationships in the quantitative data. Recruiting clinicians through PCIT listservs allowed us to reach a large number of clinicians, but only including clinicians who subscribed to the listservs and were willing to complete the survey and interviews, may have biased the sample. It is important to contextualize the findings within the sample demographics as most of our survey and interview participants were Non-Latinx White. Though a predominately non-Latinx White clinician sample is consistent with national reports on the racial/ethnic composition of mental health care providers, including in PCIT (Lin et al., 2020; Salsberg, et al., 2020; The Justice Collective, 2021), this group of clinicians might not reflect the types of adaptations made by a more diverse sample. Despite this limitation, we ensured to ask all clinicians about culturally relevant adaptions they made and oversampled Spanish-speaking clinicians in the qualitative interviews to investigate cultural responsiveness in the delivery of PCIT to the extent possible. This is noteworthy given that 30% of clinicians in our interview sample reported working with ≥50% Latinx caseloads. It is important to understand how clinicians account for culture in EBP delivery, given previous findings suggesting that cultural sensitivity and responsiveness can lead to better treatment outcomes beyond clinician-client ethnic match (Zane et al., 2005). In sum, our findings point to more systemic limitations in the field regarding the racial and ethnic diversity of the workforce, and the ability to serve linguistically diverse clients in a culturally sensitive manner. Systemic changes are needed to recruit and support clinicians from the cultural groups they serve, in an effort to enhance equity.

Additionally, our findings are limited by the use of clinician self-report. While adaptations of EBPs are expected and discussed in the literature, clinicians may hesitate to discuss these adaptations openly. Lengnick-Hall et al. (2019) found that certain factors (e.g., characteristics of supervision) seemed to hinder clinicians’ willingness to bring up adaptation-related topics. It would be important to determine if a similar phenomenon influenced the limited adaptations clinicians reported in our qualitative interviews. Lastly, the Reducing adaptations subscale yielded a low reliability score in our sample; it could be that adaptations related to removing components of PCIT were not appropriately captured. Nevertheless, clinician responses to the interviews converged with quantitative findings regarding a limited number of reducing adaptations (e.g., skipping the administration of weekly assessments due to parental literacy challenges).

Implications and Future Directions

The findings in the current study have the potential to inform training supports for clinicians providing PCIT for culturally diverse clients with clinically complex presentations, in settings with possibly increased exposure to trauma, poverty, and systemic disadvantages. The current findings also support the need to diversify the provision of evidence-based mental health services, such as PCIT, to increase reach and acceptability among a diverse community of clients (Mokrue, 2022; The Justice Collective, 2021). Because the current study did not examine clinical outcomes (e.g., treatment completion, treatment engagement, reduction of symptoms, etc.), it is crucial that future studies evaluate the impact of cultural adaptations to community implemented EBPs, such as PCIT. In a study of the implementation of cognitive processing therapy, clients that received more fidelity-consistent adaptations to the protocol had greater reductions in depression and post-traumatic stress symptoms (Marques et al., 2019). Future implementation research on PCIT should study the impact of different types of adaptations to outcomes for ethnically and racially diverse clients, with the goal of understanding how to improve engagement and outcomes for traditionally underserved populations.

Findings that clinicians made limited cultural adaptations may indicate that PCIT is already perceived to be responsive to different cultural groups, which is consistent with research findings that standard PCIT performs similarly to GANA for Mexican-Americans (McCabe et al., 2012; McCabe & Yeh, 2009). However, these findings may also point to a need for therapists to receive support in training, consultation, and supervision of the model to attend to client culture in more systemic manners. For instance, the PCIT Spanish Coalition offers an excellent home base of support and resources available to clinicians working with Spanish-Speaking families (UC Davis, 2021). In the current study, four clinicians participating in the interviews mentioned utilizing these resources. More specifically, the role of ongoing supervision and consultation in the successful implementation of EBPs has been suggested (Edmunds et al., 2013). While the current study utilized the FRAME to investigate on-the-ground adaptions of an EBP, future work could focus on evaluating on-the ground supervision and consultation as implementation strategies to support the delivery of EBPs in community settings, including proper culturally and linguistically responsive treatment delivery (Miller et al., 2021).

Another approach to supporting training in culturally responsive PCIT delivery could be through the use of assessments that maintain the client’s socio-cultural experiences at the heart of the treatment. One such approach is the application of the Cultural Formulation Interview (CFI; Lewis-Fernández et al., 2020). In their review of the state of the CFI in clinical work, Lewis-Fernandez et al., (2020) recommended its use as an essential component of assessments to guide treatment to emphasize the client’s perspective and express the clinician’s cultural humility in therapy. Additionally, the authors highlighted the CFI’s wide applicability as a training tool given that it is a brief and skills-based method. Indeed, a recent study that randomized families to receive the CFI or a standard PCIT intake found enhanced engagement outcomes, including attendance, homework completion, and treatment completion, for Spanish-speaking-families (Sanchez et al., 2022).

Lastly, it is important to consider more extensive adaptations to PCIT, including collaborations with diverse community-embedded workforces to promote culturally responsive EBPs. Particularly, involving lay health workers (LHWs) into the delivery of EBPs can help to enhance equity in access to care (Barnett, Luis Sanchez, et al., 2021). Given that LHWs tend to be trusted members of the communities they serve and share lived experiences (including understanding barriers to care), the employment of paraprofessionals to support the delivery of EBPs could be a strategy worth investing in while the field finds ways of improving the recruitment and retention of culturally and linguistically diverse providers to continue serving a wide range of families in the community (Barnett, Klein, et al., 2021; Mokrue, 2022). Multiple studies are testing LHW models to enhance access, equity, and engagement in PCIT, which could be a promising strategy extending beyond surface-level adaptations to the intervention (Davis et al., 2022).

In sum, it is important to learn from community clinicians how they adapt EBPs for their ethnically and racially diverse clients. Future work may focus on evaluating systematic training programs and materials to further augment delivery of culturally responsive EBPs, such as PCIT. Additionally, future studies are needed to investigate direct impacts of different types of PCIT adaptations on client engagement (e.g., enrollment, attendance, adherence) and clinical outcomes (e.g., skill acquisition, symptom reduction) to understand how to increase access and equity to effective parent training services for Spanish-speaking children and families.