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. Author manuscript; available in PMC: 2014 Sep 1.
Published in final edited form as: Child Youth Serv Rev. 2013 Sep;35(9):1463–1467. doi: 10.1016/j.childyouth.2013.06.003

Incorporating Natural Helpers to Address Service Disparities for Young Children with Conduct Problems

I David Acevedo-Polakovich 1, Larissa N Niec 1, Miya L Barnet 1, Katrina M Bell 1
PMCID: PMC3979433  NIHMSID: NIHMS491440  PMID: 24729649

Abstract

In response to the high levels of unmet need among historically underserved young children with conduct problems, this paper outlines some of the key issues involved in incorporating natural helpers into the delivery of parenting interventions for the treatment of conduct problems among historically underserved children. Strategies for the selection and training of natural helpers are discussed along with challenges that might be encountered in these processes. Directions for future research are also highlighted. With appropriate selection and training procedures in place, natural helpers may increase the accessibility of services for children and families and foster the reduction of service disparities.

Keywords: Conduct problems, disparities, natural helpers, prevention, parent training

1. Introduction

Conduct problems are the leading cause of mental health referrals for children (Loeber, Burke, Lahey, Winters, & Zera, 2000). Young children with conduct problems (e.g., Oppositional Defiant Disorder, Conduct Disorder, Attention Deficit/Hyperactivity Disorder [ADHD]) are more likely to develop serious conduct and emotional disorders than their peers (Lahey et al., 2009; Nock, Kazdin, Hiripi, & Kessler, 2007; Reef, Diamantopoulou, van Meurs, Verhulst, & van der Ende, 2011; Rowe, Costello, Angold, Copeland, & Maughan, 2010), and are at risk for a variety of negative outcomes as they grow older, such as incarceration, dropping out of school, drug abuse, and criminality (Fergusson, Horwood, & Ridder, 2005). Most identified pathways describing the development of delinquent and criminal behavior recognize a progression beginning with behavioral problems at young ages (Burke, Loeber, & Birmaher, 2002). In addition to their consequences for individuals, untreated conduct problems have significant costs to society such as lost productivity, legal system involvement, incarceration, and intensive treatment (Aos, Lieb, Mayfield, Miller, & Pernucci, 2004; Cohen & Piquero, 2009).

Despite these significant personal and social costs, less than half of children in the United States (U.S.) with conduct problems receive services and unmet need is even higher among U.S. children who belong to historically underserved groups such as ethnic minorities, immigrants, children living in poverty and children living in rural areas (Coker et al., 2009; Issacs et al., 2008; Merikangas et al., 2009). For example, service underutilization among African American and U.S. Latina/o children with recent conduct problems is up to 50% higher than that of European Americans (Coker et al., 2009). In all groups, families that enter treatment often do not participate fully and close to half drop out prematurely (Kazdin, 2008). Innovative service approaches are necessary to address problems with access and utilization such that outcomes for children and families can improve (Herschell, Calzada, Eyberg, & McNeil, 2002; Kazdin, 2008; Kazdin & Blase, 2011).

2. Service Responsiveness

Research examining the causes of service disparities for children and families suggests that context and culture influence the issues that families consider a problem, their understanding of the problem’s causes, and the solutions to the problem that they find acceptable (Callejas, Hernandez, Nesman, & Mowery, 2010; Cauce et al., 2002; Hernandez, Nesman, Mowery, Acevedo-Polakovich, & Callejas, 2009; Lopez & Guarnaccia, 2000). For instance, families from diverse backgrounds often seek help from individuals and settings outside of formal services (Hernandez et al., 2009). Evidence suggests that service disparities can be reduced when formal services are adapted in response to such contextual and cultural factors (Callejas et al., 2010; Hernandez et al., 2009).

Responding to cultural and contextual influences can require the consideration of novel delivery methods and settings (Issacs et al., 2008; Kazdin, 2008; Kazdin & Blase, 2011; Hernandez et al., 2009). For instance, training natural helpers to deliver evidence-based interventions to children has been proposed as a strategy to increase the accessibility and acceptability of treatment for historically underserved groups (Calzada et al., 2005). Natural helper—non mental health professionals to whom others naturally turn for advice, emotional support, and tangible aid (Israel, 1985)—have long been included in health promotion and disease prevention initiatives and more recently have been highlighted as a potential solution to service disparities (Ayala, Vaz, Earp, Elder, & Cherrington, 2010; Calzada et al., 2005; Kazdin & Blase, 2011; Koskan, Hilfinger Messias, Friedman, Brandt, & Walsemann, 2012; Rhoades, Foley, Zometa, & Bloom, 2007; Stacciarini et al., 2012). Mental health natural helpers have a wide variety of personal and professional backgrounds and may include professionals and paraprofessionals with limited mental health backgrounds (e.g, teachers, teacher aides, day care providers, clergy or other religious ministers) as well as individuals with no formal training in mental health such as valued family and/or community members (e.g., Brotman et al., 2011; Calzada et al., 2005; Stacciarini et al., 2012).

The potential benefit of incorporating natural helpers into services for historically underserved children who are at risk for conduct-disordered behavior is supported by three important sets of findings. First, natural helpers are by definition more accessible to historically underserved groups, providing services in contexts that those groups associate with help (Calzada et al., 2005; Jain, 2010; Koskan et al., 2012). Second, the research points to several strengths of trained natural helpers that are particularly relevant in engaging and treating individuals from historically underserved backgrounds, such as the abilities to establish rapport, to empathize, and to provide information and support in a manner that clients find relevant (Walter & Petr, 2006). Finally, research has documented that natural helpers who are adequately selected, trained, and supervised for the delivery of mental health interventions are more effective than passive control conditions and as effective as licensed professionals (Durlak, 1979; Hattie, Sharpley, & Rogers, 1984; Weisz, Weiss, Han, Granger, & Morton 1995; Christensen & Jacobson, 1994). For example, one recent review identified several studies in which trained natural helpers and mental health professionals were equally effective in delivering cognitive behavioral therapy for clients with anxiety and depression (Montgomery, Kunik, Wilson, Stanley, & Weiss, 2010). In response to the high levels of unmet need among historically underserved children, this paper outlines some of the key issues involved in incorporating natural helpers into parenting interventions that are focused on reducing conduct problems in young children. Suggestions drawn directly from research focused on natural helpers are complemented and expanded by suggestions from research focused on community health workers and other paraprofessionals (whenever the operationalization of these later roles resulted in the selection of natural helpers for these roles).

3. Natural Helpers and Parenting Interventions

The negative developmental trajectory for young children with conduct problems makes early intervention critical (Frick, 2000; Webster-Stratton, Rinaldi, & Reid, 2011). Longitudinal research findings suggest that the majority of adolescents whose families received treatment for early onset conduct problems are well adjusted and comparable to national norms on delinquency, sexual activity, and substance abuse (Webster-Stratton et al., 2011). Multiple effective treatments have been developed that decrease childhood conduct problems, with parent training programs recommended as a best practice for young children (Eyberg, Nelson, & Boggs, 2008; Kaminski, Valle, Filene, & Boyle, 2008; McMahon, Wells, & Kotler, 2006). The most effective parent training programs are based on a two-stage model of treatment, where the first stage teaches parents how to have warm and positive interactions with their child to promote prosocial behaviors, and the second stage focuses on how to implement effective and consistent discipline strategies (Kaminski et al., 2008). The children of parents who successfully complete parent training show improvement in their behaviors up to six years after treatment (Drugli, Larssson, Fossum, & Mørch, 2010; Hood & Eyberg, 2003).

Trained natural helpers have been used to provide parent training both in the U.S. with diverse communities (Brotman et al., 2008; Calzada et al., 2005) and abroad (Solís-Cámara & Díaz, 1999). For instance, in the United States, trained natural helpers were incorporated into the delivery of ParentCorps, a culturally informed universal preventive intervention that has been offered in urban, ethnically-diverse settings (Brotman et al., 2011). ParentCorps teaches parenting skills such as using positive reinforcement and effective discipline, and also focuses on cultural factors that are relevant to the families being served (Brotman et al., 2011). In another example, Solís-Cámara and colleagues (1999) used an intensive, three-part program to train natural helpers (primarily childcare providers) to lead parent education groups in Mexico. After this program, natural helpers gained mastery of the content and were able to deliver the program with a high level of professionalism, knowledge, and communication efficacy. Furthermore, parents in the groups led by these natural helpers demonstrated improved knowledge about child development, reduced use of corporal punishment, and increased behaviors focused on improving the parent-child relationship (e.g., reading with their children).

Although no research is available that compares the effectiveness of trained natural helpers to that of mental health professionals in the specific domain of parent training, one recent study found no differences between parenting groups conducted by nurse practitioners and professional psychologists (Lavigne et al., 2008). These findings point to the potential of natural helpers to address conduct problems in young children from historically underserved groups.

3.1 Selecting natural helpers

Although limited, the research on the selection of natural helpers has documented both individual factors that should guide the selection of natural helpers and processes by which to conduct this selection. In terms of individual factors, the personal characteristics of natural helpers appear to be of greater importance than their educational achievement (Walter & Petr, 2006; Cherrington et al., 2008). Specific personal characteristics include empathy and interpersonal warmth, the ability to stay calm in stressful situations, flexibility, patience, persistence, and enthusiasm (Walter & Petr, 2006), leadership (Cherrington et al., 2008), comfort with the subject matter (Blumenthal, Eng, & Thomas, 1999), and belief in an intervention’s effectiveness (Rodriquez, Conway, Woodruff, & Edwards, 2003). For example, a project that used natural helpers to deliver an intervention to decrease sexually transmitted diseases found that it was critical that natural helpers be comfortable discussing sex and condom use to successfully implement the intervention (Blumenthal et al., 1999). In the case of parent training, natural helpers would need to have confidence in the effectiveness of an intervention’s parenting strategies (e.g., the use of timeout as a discipline procedure) and to be comfortable discussing these strategies (Calzada et al., 2005).

In terms of selection processes, the literature favors approaches that identify individuals who either belong to the targeted population or who have extensive experience with it (Cherrington et al., 2008; Keller et al., 2012; Koskan et al., 2012). Sample selection approaches include the use of community advisory groups to identify natural helpers within the community (e.g., Blumenthal et al., 1999; Swider, Martins, Lynas, & Rothschild, 2010), the request for direct referral from other programs who have used natural helpers (Woodruff, Candelaria, & Edler, 2010), and the use of other natural helpers to identify members of their community who possess leadership qualities and community trust (Koskan et al., 2012). For example, Swider and colleagues (2010) partnered with a community-based organization to identify 10 natural helpers who had previous experience with health promotion and could be trained to deliver an intervention for diabetes management. From these 10 natural helpers, five were selected to deliver the intervention based on recommendations from the leadership of the community-based organization and on their performance in the training. Some programs assign natural helpers to deliver the intervention after establishing that they are successful in training (Calzada et al., 2005; Swider et al., 2010). Finally, it has been suggested that programs develop detailed job descriptions in order to improve their ability to select and evaluate natural helpers (Koskan et al., 2012).

3.2 Training natural helpers to deliver parenting interventions

The available literature suggests that natural helpers need adequate training and supervision to deliver mental health interventions effectively and with fidelity (e.g., Duggan et al., 2007; Easton Platt, & Van House, 1985; Jain, 2010; Swider et al., 2010). This is important because deviations from the core components of an evidence-based intervention can compromise their effectiveness and thereby their benefit to historically underserved children and families (Parra Cardona et al., 2012). Prior research has traced the failure of prevention programs delivered by natural helpers to inadequate training and supervision (Duggan et al., 2007). In order to ensure fidelity, didactic training increases knowledge among natural helpers (Luselli, Bass, & Whitcomb, 2010) and direct and formal feedback from trainers leads to natural helpers’ use of specific skills during interventions (Hall, Grundon, Pope, & Romero, 2010). For example, natural helpers’ skills improve when their supervisor observes their work as interventionists and then provides brief feedback about their strengths and areas for improvement (Leblanc, Ricciardi, & Luiselli, 2005). Natural helpers who receive this type of direct feedback until they reach a high level of mastery tend to continue to use intervention skills at post-training follow-up (Leblanc et al., 2005). Research into the performance of therapists with various levels of education suggests that this immediate and direct feedback might be especially important for natural helpers, as therapists without a master’s degree perform better when they receive in vivo supervision whereas clinician’s with a master’s degree perform well with videotape review and delayed feedback (Carpenter et al., 2012). Another model of training and supervision involves partnering a natural helper with a professional to deliver an intervention (Calzada et al., 2005; Dubus, 2009). For example, mental health professionals and Cambodian interpreters provided treatment in a team-based model, which extended beyond traditional professional/interpreter roles to improve the cultural sensitivity of services (Dubus, 2009).

The work of Calzada and colleagues (2005) provides a useful example of a program that trains natural helpers as parent trainers in historically underserved ethnic minority communities. As a response to the range and variety of educational and social backgrounds of natural helpers, the didactic portion of the program is structured but informal. After didactic training, natural helpers assist trained professionals in delivering the intervention, taking on increased responsibilities as they improve their skills and comfort. Natural helpers receive feedback on their performance from co-therapists and participate in formal supervision. Furthermore, they received formal group supervision from licensed clinical psychologists. This training program consisted of 38 weeks of training that occurred over approximately one year. The length of training was determined to allow adequate didactic and experiential learning. Although this training program is still under investigation, it provides initial evidence that natural helpers within historically underserved ethnic minority communities can be successfully trained in parenting interventions.

4. Discussion

Existing literature suggests that incorporating natural helpers into parenting interventions that are focused on reducing conduct problems in young children from historically underserved groups may improve the availability, accessibility, utilization and effectiveness of these interventions. The significant personal and social costs associated with untreated conduct problems highlight the potentially significant impact of incorporating natural helpers into these interventions and underscore the importance of future research that can carefully examine the conditions under which natural helpers can most effectively be incorporated into this service domain.

The incorporation of natural helpers is not without its challenges. The wide range of backgrounds and educational experiences that characterize natural helpers can pose a significant hurdle for the development of training programs (e.g., Calzada et al., 2005). In the specific domain of services for children with conduct problems, reasonable concerns can be raised about the selection and training that would be required to ensure that natural helpers are qualified to manage the challenges that can be presented by children with clinically significant conduct problems. For instance, given the elevated rates of comorbidity and family pathology that can be found among these children (Hinshaw& Lee, 2006), a broader formation in mental health triage—such as that provided by the mental health first aid curriculum (Kitchener & Jorm, 2002)—might be in order.

In addition to technical skills related to parent training and mental health triage, natural helpers might also need to be provided with guidance regarding the multiple ethical issues that can arise when working with underserved families (Jain, 2010). The work done to develop ethical principles and practices for other natural helper groups, including adults who mentor youth (e.g., Rhodes, Liang, & Spencer, 2009), can serve as a model. Based on the American Psychological Association’s code of ethics, said principles help adults ensure that their practices are responsive to the interests and rights of the youth whom they mentor (Rhodes et al., 2009). Similarly, natural helpers who are trained to provide parenting interventions should be provided with training and guidance regarding ethical behavior in this specific role. Stakeholders who wish to examine the potential of incorporating natural helpers into mental health services will have to account for these important issues. A summary of suggestions from the research literature on incorporating natural helpers into services is provided in Table 1.

Table 1.

Summary of the Research Literature on Incorporating Natural Helpers as Interventionists

Domain Findings
Characteristics of Effective Natural Helpers Empathy1,2
Interpersonal warmth1,3
Ability to manage stress1,2
Flexibility1
Patience1
Persistence1
Enthusiasm1
Leadership3,4,5
Comfort with the subject matter4,6
Belief in an intervention’s effectiveness4,7
Extensive experience with—or membership in—the target population2,3,5,6
Selection Process Referral from community advisory groups6,7
Referrals from other community groups that use natural helpers3,5
Select natural helpers who successfully complete training4,8
Training as Parenting Interventionists Didactic training adapted in response to varying educational levels3,4,5,7,8
Direct in vivo feedback4,8
Ongoing supervision until mastery criteria are met4,6,8,9
Additional Training Behavioral health triage and referral10
Ethical principles2,11
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Note.

4

Calzada et al., 2005;

One particularly promising direction for the incorporation of natural helpers into services for historically underserved young children with conduct problems lies in the domain of prevention. Many of the concerns that can be raised to the incorporation of natural helpers into services for children with clinically significant conduct problems are eliminated or assuaged if the focus of an intervention is preventive rather than curative or palliative. For instance, compared with children who meet clinical thresholds, lower rates of comorbidity and family pathology might be expected among children with sub-clinical conduct problems.

Despite the many potential benefits of incorporating natural helpers into services for children with conduct problems, many important questions about doing so should be addressed in future research. Studies are needed that build upon existing efforts to document that natural helpers can in fact be trained to deliver preventive parenting interventions with fidelity and effectiveness (e.g., Calzada et al., 2005; Katz et al., 2011; Solís-Cámara & Díaz-Romero, 2009). Comparative research examining the effectiveness and cost of these interventions when delivered through natural helpers and traditional mental health providers can then be conducted to inform policy and practice (e.g., Charles, Edwards, Bywater, & Hutchings, 2013; Katz et al., 2011). Such comparative studies would do well to focus on identifying characteristics of families and children that may moderate the effects of interventions delivered by natural helpers, thereby guiding policy and practice decisions about the service settings that might best suited to incorporating natural helpers.

While the focus of this article has been on the role of trained natural helpers in reducing disparities for children with conduct disordered behavior who come from historically underserved groups, the involvement of natural helpers has potential benefits across a wide variety of mental health service domains. This is because the disparities faced by these children are a reflection of broader patterns of service disparities in the U.S. (Kazdin, 2008; Kazdin & Blase, 2011). While more than 50% of the U.S. population will meet criteria for at least one psychiatric disorder during their lifetimes (Kessler & Wang, 2008), most individuals who need mental health treatment will not receive it (e.g., Merikangas et al., 2009; Kazdin, 2008; Kessler et al., 2005), and unmet needs are even higher among ethnic and racial minorities (Isaacs et al., 2008; Kazdin, 2008; Kazdin & Blase, 2011). With appropriate selection and training procedures, natural helpers can help make services accessible to children and families who are in need of them and help to reduce service disparities.

Highlights.

  • About half of children needing treatment for conduct problems do not receive it.

  • Unmet need doubles among children historically underserved children.

  • Incorporating natural helpers into best practices may help address unmet need.

  • Relevant research is reviewed; Practice and research implications are discussed.

Acknowledgments

The preparation of this article was supported in part with funding from the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number R21HD074269. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

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