Working Together to Solve Disparities: Latina/o Parents’ Contributions to the Adaptation of a Preventive Intervention for Childhood Conduct Problems

Abstract

Left untreated, conduct problems can have significant and long-lasting negative effects on children’s development. Despite the existence of many effective interventions, U.S. Latina/o children are less likely to access or receive evidence-based services. Seeking to build the foundation to address these service disparities, the current study used a Community-Based Participatory Research approach to examine U.S. Latina/o parents’ perceptions of the need for interventions to prevent childhood disruptive behaviors in their community in general, and of an existing evidence-based intervention—parent-child interaction therapy (PCIT)—in particular. Results suggest that parents recognize a need for prevention resources in their community and value most of the core features of PCIT. Nevertheless, important directions for potential adaptation and expansion of PCIT into a prevention approach were identified. Results point to several goals for future study with the potential to ameliorate the unmet mental health needs experienced by U.S. Latina/o families with young children at risk for developing conduct problems.

Disruptive behavior disorders such as Oppositional-Defiant Disorder and Conduct Disorder are some of the most frequently diagnosed conditions in young children, with prevalence estimates ranging from 1% to 16% in the general population (American Psychiatric Association, 2000). Many risk factors for the development of these disorders are disproportionately prevalent among historically underserved groups, including U.S. Latina/o¹ children. For instance, poverty and exposure to violence—two risk factors for the development of conduct problems—are disproportionately prevalent among U.S. Latina/o families (DeNavas-Walt, Proctor, & Mills, 2004; Nicolaidis, 2011). Many Latina/o families also experience psychological, somatic, and social difficulties as result of acculturation processes (Canino & Alegria, 2009). Such difficulties have been linked to higher rates of conduct problems in children (Canino & Alegria, 2009).

The high risk for conduct problems among children in US Latina/o communities is of particular concern for two primary reasons. First, because of the serious short- and long-term negative consequences that are associated with these problems (Burke, 2009; Loeber, Burke & Pardini, 2009; Moffitt, Caspi, Harrington, & Milne, 2002). Second, because—reflecting an overall service disparity among U.S. Latina/o families (e.g, Algeria, Canino et al., 2004; Chow, Jaffee, & Snowden, 2003)—U.S. Latina/o children with conduct problems are significantly less likely to have accessed mental health services than European American children (26% versus 40%; Coker et al., 2009). In some studies, less than a third of U.S. Latina/o children with a disruptive behavior disorder receive treatment (e.g., Alegria et al., 2004). Even when US Latina/o parents seek services for their children, they are more likely to prematurely terminate services than White parents (McCabe et al., 1999), increasing the likelihood that their children will not receive the full benefits of the services.

The underutilization of mental health services by US Latina/o families of children with conduct problems is explained in part by the mismatch between the context and culture of the traditional mental health system and the culture and context of Latina/o families (Acevedo-Polakovich, Crider, Kassab, & Gerhart, 2011). In terms of context, fewer mental health services tend to be available or accessible in areas where large numbers of historically underserved families live (Alegria et al., 2004). Even when services are available, they are often not responsive to the cultural values of Latina/o communities (Acevedo-Polakovich et al, 2011). For instance, many Latina/o groups associate significant stigma with mental health care (Guarnaccia, Lewis-Fernandez & Rivera-Marano, 2003), which is reinforced in local communities as a result of negative experiences with available services (Vega & Lopez, 2001).

Cultural Adaptation of Mental Health Interventions

Cultural adaptations of evidence-based interventions are increasingly viewed as a valuable solution to address the mental health services disparities faced by Latina/os and other historically underserved populations (e.g., Bernal & Saez-Santiago, 2006; Isaacs et al., 2008). Important benefits such as increased service availability, accessibility, utilization and effectiveness have been demonstrated from cultural adaptation (Hernandez, Nesman, Mowery, Acevedo-Polakovich, & Callejas, 2009). Meta-analytic results suggest that practices that are responsive to specific cultural groups have effect sizes that are on average four times larger than those of broadly targeted practices (Griner & Smith, 2006; Smith, Domenech Rodriguez, & Bernal, 2011). Even adaptations as simple as offering services in a client’s native language (if other than English) lead to effect sizes that are twice as large (Griner & Smith, 2006). Culturally adapted services are often perceived by historically underserved groups as more acceptable and less threatening than unadapted services (Griner & Smith, 2006; Harachi, Catalano, & Hawkins, 1997), and perhaps as a result, these historically underserved individuals are more likely to complete culturally adapted interventions successfully than those who receive unadapted services (Kumpfer, Alvarado, Smith & Bellamy, 2002).

Preliminary efforts have been made to culturally adapt evidence-based interventions for children with conduct problems (e.g., Domenech-Rodriguez, Baumann, & Schwartz, 2011; Martinez & Eddy, 2005; McCabe & Yeh, 2009). Adapted versions of parent management training–Oregon Model (PMTO) and parent-child interaction therapy, for example, are generally effective with US Latina/o families who have a child with conduct problems, and these adapted interventions can lead to improved retention and satisfaction (e.g., Domenech et al., 2011; Martinez & Eddy, 2005; McCabe & Yeh, 2009). However, there remains a dearth of research on culturally adapted evidence-based parenting interventions (Parra-Cardona, et al., 2012) and significant problems exist with accessibility and availability. For example, US Latinas/os’ distrust of formal mental health services settings and their tendency to seek mental health help from other sources (including friends, family, and community members) raises the possibility that adaptations delivered in formal mental health settings may not be accessed at rates that match the need for them.

Working with, rather than against, the cultural values and beliefs of Latinas/os and other historically underserved groups in order to address disparities requires novel approaches to services (Kazdin, 2008) and services research (Wallerstein, 2006; Wallerstein & Duran, 2006). For instance, services might be expanded to incorporate a broader range of settings and providers such that they are responsive to US Latinas/os cultural preferences for help seeking (Acevedo-Polakovich et al., 2011; Hernandez, et al., 2009). Typically, the expansion of services into settings that are not traditionally associated with mental health, such as schools and primary care settings, has rendered positive results in terms of engaging historically underserved groups, including US Latina/o families, into services (Atkins et al., 2006; Manoleas, 2008). Latinas/os are more likely to seek help or advice regarding their children’s mental health problems from friends, family, community members or their medical doctors than to contact a mental health professional (Callejas et al., 2006; McMiller & Weisz, 1996). One innovative approach to addressing mental health services disparities among US Latina/o children is to incorporate the individuals to whom their families naturally turn for help (natural helpers) into the services infrastructure (Acevedo-Polakovich, Niec, Barnett & Bell, 2013; Calzada et al., 2005).

Prevention of Conduct Problems among Latina/o Children

Significant challenges surround the use of natural helpers within services settings (Acevedo-Polakovich et al., 2013). Reasonable concerns can be raised about the selection and training that would be required to ensure that these individuals—who often do not have formal mental health training—could appropriately manage the difficulties presented by children with conduct problems. Despite promising findings regarding the effectiveness of mental health services delivered to historically underserved populations by carefully selected and trained community members (e.g. Jain, 2010), the challenges of delivering services in this manner are substantial. Many of the challenges are eliminated or assuaged, however, if the focus of an intervention is on the prevention of disruptive behavior disorders rather than their treatment (Acevedo-Polakovich et al., 2013). Selective preventive interventions target families with children at risk of manifesting a problem (Munoz, Mrazek, & Haggerty, 1996). Compared to children who meet the full criteria for mental health disorders, children at risk for disorders can be expected to have lower rates of comorbidity and family pathology. The sequelae of conduct problems are extremely costly to individuals, families and society, and evidence suggests that addressing them early can be cost effective (O’Neill, McGilloway, Donnelly, Bywater & Kelly, 2013). Further, because selective preventive interventions address a range of risk and protective factors, they are appropriate for a broader segment of US Latinas/os, and therefore carry the potential to have a much broader public health impact (Beardslee, Chien, & Bell, 2011).

Natural helpers may offer a promising solution to the problems of service access, availability and utilization. By definition, natural helpers are more accessible to the community they serve than professionals in formal service settings (Calzada et al., 2005) and families are often more likely to turn to them for help (Callejas et al., 2006; McMiller & Weisz, 1996). Although research has not yet examined differences in outcomes between natural helpers and credentialed mental health professionals in the context of the proposed parenting approach, recent investigations of other types of psychological interventions (e.g. cognitive behavioral therapy) have demonstrated that natural helpers have outcomes comparable to mental health professionals (Montgomery, Kunik, Wilson, Stanley, & Weiss, 2010).

Innovative Treatment into Innovative Prevention

Parent-Child Interaction Therapy is an evidence-based behavioral family intervention developed to treat conduct problems in children two to six years-eleven months of age. It is administered to a family by a therapist with a minimum of a master’s degree in a mental health field and specialized training in PCIT (PCIT International, 2013). PCIT is implemented in two phases: The first phase focuses on enhancing the parent-child relationship and building parents’ non-confrontational behavior management skills. The second phase builds parents’ effective discipline skills. PCIT has considerable research support (see Niec, Gering, & Abbenante, 2011 for a review). Successful completion of PCIT results in significant gains in positive parenting skills and reductions in child conduct problems, with maintenance of gains as long as six years post treatment (Hood, & Eyberg, 2003).

Several important characteristics suggest that the adaptation of PCIT into a selective preventive intervention can have a significant public health impact among U.S. Latinas/os. First, PCIT addresses key risk factors for the development of childhood conduct problems. By focusing equally on the development of the parent-child relationship and the development of parents’ behavior management skills, PCIT tackles two risk factors for the development of adverse outcomes: parent-child conflict and ineffective parenting strategies (e.g., Campbell, 1995; Stormont, 2002). By intervening with children two to nearly seven years of age, PCIT targets a critical period for the prevention of conduct problems (McMahon, 1994; McNeil, Capage, Bahl, & Blanc, 1999). Compared to children who receive intervention for conduct problems after eight years of age, younger children demonstrate significantly greater improvement (Frick, 2000).

Second, PCIT uses innovative mechanisms to elicit parent behavior change. In contrast to most other approaches to parent training, which tend to focus on didactic instruction, modeling, and role play (Sampers, Anderson, Hartung, & Scambler, 2001), during PCIT, parents are coached in the use of skills during live interactions with their children. The live coaching component of PCIT allows interventionists to assess parenting behaviors directly and to provide feedback immediately, rather than to depend only on parents’ reports. A meta-analysis of parenting interventions indicated that requiring parents to practice skills in session with their children is related to greater effect sizes both in the development of positive parenting behaviors and in the reduction of conduct problems (Kaminski, Valle, Filene, & Boyle, 2008). Further, PCIT coaching has been shown to improve parent-child interactions even without extensive didactic sessions (Shanley & Niec, 2010), which suggests that a less intense, preventive model might also be effective in improving parenting skills. Perhaps most notably, among historically underserved families, active practice of parenting skills, such as that used in PCIT, has been shown to be more effective than reading and discussion (Knapp, & Deluty, 1989)

A third aspect of PCIT that makes it promising as a preventive model for Latina/o families is that PCIT integrates aspects of interventions described by US Latina/o populations as important and desirable. Prior research has identified several components of parenting programs that are important to US Latina/o families such as a collaborative relationship between the interventionist and parent, the enhancement of the parent-child relationship, and the inclusion of multiple families in the intervention (McCabe & Yeh, 2009, Martinez, & Eddy, 2005, Parra-Cardona et al., 2009). PCIT places strong emphasis on a collaborative therapist-parent relationship (e.g., via coaching) and on strengthening the parent-child relationship, and can be effectively delivered in a group format (Niec, Yopp, Hemme, & Brestan, 2005).

Finally, PCIT is driven by ongoing direct assessment of actual behaviors. Parents’ and children’s behaviors are assessed weekly with a standardized behavior analogue measure (DPICS; Eyberg, Nelson, Duke, & Boggs, 2005) that is less prone to the biases inherent in parent-reported rating scales. This allows a focus on actual interactions between parents and children, which are better predictors of future outcomes than parent or teacher reports of child behavior (Patterson & Forgatch, 1995).

These four advantages of PCIT highlight the potential benefits of its adaptation into a preventive intervention for Latina/o families. Preliminary evidence also supports the effectiveness of PCIT as a clinical intervention with U.S. Latinas/os (McCabe & Yeh, 2009) and its effectiveness as a preventive intervention when delivered to non-Latinas/os (Berkovitz, O’Brien, Carter, & Eyberg, 2010). In the piloted prevention model, thirty parents participated in either a four-session group intervention that included two sessions of didactic and two sessions of coaching or a self-directed reading intervention. Both models demonstrated reductions in child behavior problems. Although a promising early step, a number of features of this adaptation limit its relevance to historically underserved families: The study sample was primarily composed of Caucasian families; the preventive intervention was implemented in a primary care setting rather than a community setting; and therapists were doctoral students with extensive experience in PCIT rather than the natural helpers from whom underserved populations often receive assistance. Further, children’s and parents’ outcomes were assessed by parent report with no evaluation of actual observed behavior change.

Thus, while no research has directly examined the use of PCIT as a preventive intervention delivered to Latina/o families by trained natural helpers, its favorable characteristics and the promising findings of prior studies provide strong support for such an examination.

Community-engaged Steps toward Culturally responsive Prevention

The adaptation of a culturally responsive intervention is a multi-step process. Our study was guided in part by the Cultural Adaptation Process (CAP), which begins with qualitative inquiry into a community’s needs and its perceptions of existing interventions (Domenech-Rodriguez & Wieling, 2004). Such inquiry informs the identification of interventions that may meet community needs as well as adaptations to such interventions that seem likely to increase their cultural and contextual relevance. Only after qualitative inquiry is a proposed intervention developed and piloted, allowing for an initial examination of its feasibility, effectiveness and acceptability in the community.

A number of other approaches have been advanced that meaningfully place members of historically underserved communities at the core of the research process (Acevedo-Polakovich, Kassab, & Barnett, 2012). Our study was further guided by one of these approaches, Community-Based Participatory Research (CBPR), which stresses genuine collaboration between researchers and communities (Wallerstein & Duran, 2006). CBPR has successfully been used in work with historically underserved populations to address a wide range of health and social issues (Wallerstein & Duran, 2006).

Guided by the principles of CBPR and informed by the CAP, our primary goal in the current project was to explore the opinions and beliefs of Latina/o parents in the local community regarding parenting programs in general and the evidence-based intervention PCIT in particular. While doing so, we hoped to document adaptations that would likely have to be made to PCIT to ensure responsiveness to cultural and contextual factors. Given the promise of training natural helpers as community preventionists, we also wished to explore community reactions to this idea. The CBPR partnership members determined that the current study should address the following questions: (1) Is a preventive parenting program needed in this community? (2) What characteristics would make a preventive parenting program useful and appropriate for Latina/o families? (3) Do the core components of PCIT meet the needs of Latina/o families for a preventive parenting program? (4) How can PCIT be tailored to work efficiently and effectively as a preventive program within the community?

Method

In order to ensure continued adherence to CBPR principles, all research activities were monitored by an Advisory Group composed of two personnel from the community partner agency, two representatives from other community agencies with experience delivering services to local Latina/o families, two representatives from local Latina/o parent groups, and the two academically-based lead authors of this paper. In order to ensure an in-depth exploration of participants’ knowledge, experiences, and context (Creswell & Plano Clark, 2007; Kitzinger, 1995), an exploratory qualitative focus group approach was selected.

Participants

To be eligible for study recruitment, participants had to (1) identify themselves as Latina/o and (2) have at least one child between the ages of two and seven. Recruitment was limited to current parents of young children because they are the target population of the proposed prevention program. Participants were recruited from the geographical area served by the community organization partnered in this research, a community center serving U.S. Latinas/os in a mid-sized Midwestern city. Services provided by the organization include, but are not limited to, family support services, domestic violence support, immigration assistance, comprehensive youth services, and certification training for home daycare providers. The facilities of this community organization are located in the midst of a predominately Latina/o and economically disadvantaged area of the city.

Recruitment efforts led to the participation of fifty-two individuals aged 16 to 51 years (M = 34.12, SD = 9.01) in one of six focus groups. Each group contained 8–9 participants. One participant reported having no children, but indicated she was pregnant, and one participant declined to provide information regarding young children. Therefore, fifty participants reported having at least one child within the age range. A majority of participants (n = 46) were female. Forty-three percent of participants were married, 24% were living with a partner and 33% were single.

All participants reported their ethnic background as Hispanic or Latina/o, with specific heritages including Mexican (73%), Guatemalan (10%), Puerto Rican (4%), Cuban (4%), Mexican-American or Chicana/o (2%), and Salvadoran (2%). The remaining participants either did not indicate a specific Latina/o heritage or reported having a mixed ancestry. When provided with an option to select the race categories used by the U.S. Census and “other,” 40% of participants selected “other” and wrote in a Latina/o heritage, 30% did not select an option, 10% selected White, 8% selected Native American, 6% selected Black, and 6% selected “other” without further clarifying. This pattern of responses regarding race and ethnicity aligns with extensive research suggesting Latinas/os most often select their specific Latina/o heritage as an identifier rather than pan-ethnic terms such as Latina/o or Hispanic or racial identifiers such as those demanded by the U.S. Census (Taylor, Lopez, Martínez, & Velasco, 2012).

Seventy-five percent of participants were immigrants to the United States. The most common national origins of immigrants included Mexico (58%), Guatemala (6%), Cuba (4%), and El Salvador (2%). Forty-six percent preferred speaking Spanish, 21% were comfortable with both English and Spanish, and 12% preferred English. Participants’ educational attainment ranged from completing elementary school to obtaining a college degree. Seventy percent of the participants reported completing some high school, and 30% of participants reported earning a high school degree. Participants estimated their annual household income as a marker of SES. Thirty-six percent (n = 19) of the sample reported earning less than $10,000 per year; sixty-three percent (n = 33) indicated an annual income of less than $20,000.

Measures

Demographics

A demographics form developed by the primary investigators and reviewed by our Advisory Group was completed by each participant. The demographics form was available in English and Spanish. Participants selected the version they felt most comfortable completing.

Focus group guide

An outline was developed to guide focus group discussions such that they sequentially obtained information about each of the study’s guiding questions. When discussing specific components of PCIT, sample videos were shown that demonstrated these components.

Procedure

Participants were recruited by the community organization partnered in this research and all focus groups were conducted at its facilities by trained members of the research team. Groups were formed according to the language preferences of participants such that five groups were run in Spanish and one was run in English. Each group lasted 90 to 120 minutes. All participants received $30 compensation for their time.

Upon arrival, parents were greeted by a member of the bilingual research team, guided through the consent procedure, and—if informed consent was provided–asked to complete the demographics form. No individuals declined to participate. All groups were audio recorded. Each group was transcribed in the language in which it was conducted, and then verified for accuracy by the second author, a native Spanish speaker with a record of professional publications and presentations in Spanish.

Results

Parent Focus Groups

Following the transcription of each focus group, the transcripts were qualitatively analyzed for thematic content using a procedure modeled from that described by Marshall and Rossman (1995). Two coders, both fluent in English and Spanish, independently reviewed the transcripts, identifying themes, defining themes, and recording specific instances of the themes. Comparison of their results revealed that the coders had agreed on 63.2% of instances. To improve upon this initial convergence, the lists of themes were reviewed by the research team, which included experts on PCIT and on services for U.S. Latinas/os. Based on this review, a list of 47 themes grouped into eight categories was generated (Table 1). The coders then independently analyzed each transcript. When their results were compared, the coders were convergent on 753 instances out of a possible 816 (convergence estimate of 92.3%). Any remaining instances of non-convergence were solved by discussion among the research team. Results were then discussed with the Advisory Group. Below we describe each of the eight themes and follow with a discussion of how they assist in answering the study questions.

Table 1.

Themes and Instances

Category	Theme	Instances
Need for and Availability of Parenting Help
	Acting Out Kids Exist	52
	Parenting is Challenging	51
	Public Behaviors are Challenging	33
	Caregivers’ Discrepant Parenting	38
	Need for More Parenting Services	32
	Teen Parents are in Need of Parenting Services	4
	Help is Available in the Community	24
Parenting Beliefs and Practices
	Terms for Acting Out Kids	40
	Parents are the Authority and Children Should Obey	14
	Parents Model Behaviors	7
	Parents Need to be Consistent	11
	Parents Need to Set Limits	18
	Parental Attention is Important	16
	Children Act Out to Get Their Way	6
	Ignoring Is Used	20
	Positive Reinforcement Works	2
	Parents use Time-out	18
Fathers and Parenting
	Fathers Would Benefit From a Parenting Program	10
	Fathers Have Limited Involvement With Children	14
Parent Reactions to Specific PCIT Components
	Positive Reactions to Phase 1 of PCIT	30
	Concerns with Ignoring	6
	Positive Reactions to Ignoring	9
	Coaching would be Helpful for Some People	19
	Negative Reactions to Coaching	15
	Positive Reactions to Coaching	15
	Positive Reactions to Didactics	15
	Positive Reactions to PCIT Commands	15
	Positive Reactions to Mr. Bear	18
	Negative Reactions to Mr. Bear	18
	Positive Reactions to Time-out	4
	Negative Reactions to Time-out	20
Program Suggestions
	Alternatives to Coaching	9
	Home Visits Could Increase Accessibility	2
	Other Caretakers Should be Included in Treatment	20
	Only Parents Should be Involved in Treatment	13
	There Should be Group and Individual Sessions	6
	Community Members Should Teach Parenting Groups	17
	Professionals Should be Parent Group Leaders/Coaches	15
	Benefits to Group Treatment	18
	Use of Information to Promote the Group	11
Barriers to Parenting and/or Parenting Programs
	Immigration Issues are a Source of Stress	12
	Barriers to Participating in a Child’s Life	9
	Lack of Follow-Through with Parent Training	4
Cultural Considerations
	Time-out is not Common in Latin America	2
	Education is Important	16
	Treatment Needs to be Tailored to Each Family	5
	Acculturation Stress	12
Physical Punishment and Abuse
	Corporal Punishment/Harsh Parenting Practices Exist	27
	Negative Reactions to Corporal Punishment/Harsh	8
	Desire to Learn How to Use Physical Punishment Legally	15
	Parents are Worried about being Called Abusive	7

Need for and Availability of Parenting Help

Parents’ thoughts about the need for help with their parenting generated seven major themes (Table 1). The overarching ideas among the themes were that children with conduct problems exist within the Latina/o community and that Latina/o parents are often challenged by their behaviors (e.g., “…being a mom, it’s not easy.”, “You don’t know if you should like, yell at him, you know?”, “We don’t know these techniques, nobody has taught us”). Parents also felt that adequate parenting resources do not exist within the community. One participant said, “I don’t think we will ever see enough,” and another added, “My point of view: we need more.”

Parenting Beliefs and Practices

Common among the 10 themes in this category was the concept that parents are the authority within the Latina/o family. When discussing interacting with her child, one participant said, “…you go do it. I’m the boss. That’s why.” Another participant emphasized, “I just want him [the child] to know that I’m the boss.” It was also acknowledged that, as authority figures, parents must set limits and be consistent with their discipline, because parents’ behaviors influence children’s behaviors. This category also included parents’ descriptions of the discipline strategies they commonly use, including ignoring children’s attention-seeking behaviors, positive reinforcement (e.g.,“High fives definitely work.”), and time-out.

Fathers and Parenting

This category included two themes that describe particular challenges Latino fathers face in terms of parenting. Parents expressed the belief that fathers need help with parenting skills for various reasons, including a lack of involvement with their children and/or not knowing how to manage child behavior. One participant described how fathers’ responsibilities take away from time with their children, “…even more so in Hispanic families it seems like the man, he works, and then he doesn’t have a lot of interaction with the kids so much. So you know, I think it’s a good thing that you have that kind of training.” Particular challenges for fathers that could be addressed in a parenting program were also mentioned (e.g., “Sometimes fathers lack patience.”).

Parent Reactions to Specific PCIT Components

Throughout the focus groups, participants heard verbal descriptions of PCIT and watched video clips demonstrating parts of the program. This category includes 12 themes that describe parents’ reactions to core components of the program including the skills taught and the methods of teaching. Overall, parents saw value in the focus of the first phase of the proposed intervention: that is, enhancing the parent-child relationship (e.g.,“… that about praises is very good because… it makes them feel important.”). Parents expressed mixed attitudes toward specific behavior modification techniques such as time-out and ignoring (e.g.,“ Sometimes it’s a little hard to ignore them.”; “It’s a very good technique.”). Live coaching of parent-child interactions, which is a key component of PCIT, also elicited mixed responses (e.g., “I wouldn’t need it, but uh, you know, I think it’s a good thing.”; “For me it’s good also because sometimes we think that we are doing everything well, but no, we can’t catch our mistakes… So it’s good to have someone correct us”).

Program Suggestions

Focus group participants were encouraged to provide suggestions for the way in which a PCIT-based preventive intervention could best meet the needs for Latina/o families. Nine themes arose from the discussion. Some parents suggested that a group format would be most useful for a preventive intervention (e.g., “More people because that way one learns from examples that others give.”), while other parents suggested that a combination of group and individual sessions would be useful in order to tailor the program to families, yet still provide the opportunity to share experiences. A number of parents expressed the importance of including extended family members or other caregivers in the prevention program. However, some parents suggested that including grandparents can be intimidating for parents who are struggling to assert their authority.

Because a key aspect of the proposed preventive intervention is implementation by natural helpers, parents were asked who they believed should lead prevention groups for Latina/o families. Parents suggested various community members including the police (e.g., “…even if there was somebody from, like, law enforcement.”), community elders, and grandparents (e.g., “If they look up to their own parents or to have their own parent come in to coach them through, so that they’re more comfortable.”). Some suggestions included “specialists” (i.e., “Psychologists,” “Social Workers”).

Parents suggested that a prevention program would be likely to engage more families if informational group meetings were held prior to the program’s start to allow parents to ask questions and meet other potential participants.

Barriers to Parenting and/or Parenting Programs

Participants shared three types of barriers they might face in parenting their children or in attending and benefiting from a parenting program. One barrier was specific to an immigrant population (e.g., “Right now, the, the Mexican population or immigrants are living in fear.”), but other barriers were those often reported by families entering a parenting program (e.g., inability to follow through and time constraints: “But like mine [husband], right now can’t come because he is working.”).

Cultural Considerations

Four themes arose that highlighted shared and divergent cultural values within the Latina/o community and between the Latina/o community and American culture. For example, in response to discussions about time-out, one participant said, “This is good because there in our countries they don’t use that much.” Although parents shared cultural differences and the stresses experienced because of those differences, they also expressed the desire to have prevention programs that are sensitive to each individual family’s needs and values: “Maybe incorporating some of that, uh, like what we hold as family values…”

Parents expressed that differences between their culture of origin and American culture sometimes lead children to misbehave and increases parent-child relationship problems. One participant explained how their child’s difficulty in accepting American and Hispanic culture is challenging, “…they want to be on this side, but they don’t want to accept their own. So there is our work, but it’s a lot of work.”

Physical Punishment and Abuse

Although corporal punishment was not an explicit area of inquiry within the focus group guide, the topic arose spontaneously in the majority of groups. Some parents described harsh discipline practices they or others practice (e.g., “I put him in a corner make him stand straight up, his arms straight to the side, nose right in the middle of the corner.”). Other parents indicated displeasure with corporal punishment (e.g., I’m like, well, you don’t just go hitting on kids, you know what I mean?”). Parents sometimes expressed a desire to better understand the discipline practices that are or are not considered acceptable within the United States (e.g., “What type of hitting is ok…maybe a thump or a spank, is that ok, you know?”). Also captured by this category was the concept that physical punishment should be included in a parenting program (e.g., “…because it’s unrealistic to teach parents don’t ever hit your child, because it’s going to happen.”).

Discussion

Childhood conduct problems can have significant negative consequences in multiple domains of functioning through childhood and into adulthood (e.g., Burke, 2009; Loeber, Burke & Pardini, 2009). Although US Latina/o children are more likely to experience risk factors associated with conduct problems (DeNavas-Walt, et al., 2004; Canino & Alegria, 2009), Latina/o children are less likely than non-Latina/o White children to receive mental health services (Coker et al., 2009). Guided by CBPR principles, we used a qualitative approach to take a first step toward adapting an evidence-based treatment into a preventive intervention responsive to the needs of Latina/o families.

Is a preventive parenting program needed in this community?

Results suggest that participants recognize a need for assistance with parenting issues, both for themselves and in their broader community. These qualitative results are consonant with findings that levels of unmet need among U.S. Latina/o parents of children with conduct problems exceed those observed among the general population (e.g., Merikangas et al., 2010). Our findings expand on previous results by documenting that—at least in one community—parents are aware of their unmet needs and are interested in bringing services to their community. It is possible that current findings are partly influenced by the fact that our discussion did not frame the solution as requiring the involvement of licensed mental health professionals, thereby not activating the bias associated with these professions documented in prior research (Alegría et al, 2004)

What characteristics would make a preventive parenting program useful and appropriate for Latina/o families?

At their broadest, results suggest that a preventive parenting program would have to address values rooted in participants’ Latina/o heritage and also the impact of immigration and acculturation on their families. This finding is consistent with earlier research exploring the adaptation of PCIT as a treatment intervention for Latina/o families (McCabe et al, 2005). For instance, participants regularly referred to parents as the leaders of the family with ultimate authority over family decisions. A successful preventive program should respond to this conception of parents, perhaps by emphasizing the manner in which parenting practices can teach, model, and reinforce the Latina/o concept of respeto (Garcia, 1996).

Participants also identified important factors affecting family functioning that were related to the experiences of immigration and acculturation. Parents talked about the difficulties that they and their children experience in balancing the retention of their ethnic heritage and the development of proficiency with the values and beliefs that characterize U.S. culture. Importantly, differential acculturation patterns within families have been described in the existing literature as a source of family dysfunction and problem behavior among children (Acevedo-Polakovich & Gering, 2012; Szapocznik et al., 1986). An effective parenting preventive program should address these concerns and help families foster functional acculturative patterns.

Participants felt that fathers in their community were prevented from successful involvement in their children’s lives both by practical barriers (e.g., demanding work schedules) and a lack of familiarity with effective parenting techniques. Nevertheless, participants felt that fathers’ involvement in a preventive program was key to the success of any changes in family practices. Research has suggested that fathers’ involvement improves outcomes in parent-training interventions for conduct-disordered behaviors (Bagner & Eyberg, 2003; Webster-Stratton, 2003) and that fathers are also significantly less likely to participate in interventions for their children (Tiano & McNeill, 2005). For maximal public health impact among U.S. Latinas/os, preventive parenting interventions must successfully engage fathers.

Consistent with prior research documenting the use of corporal punishment among some U.S. Latina/o parents (e.g., Calzada, Basil, & Fernandez, 2012), participants suggested that the issue of corporal punishment would have to be dealt with directly, as it is part of the parenting practices of families in their community. Corporal punishment as a component of parental discipline is not generally more effective than more humane alternatives, reduces the likelihood that parents will discipline their children using said alternatives, and can increase the risk that children are mistreated (Gershoff, 2002). For these reasons, ensuring that parents are provided with education on the potential adverse effects of corporal punishments and training in healthy alternatives should be an important component of any preventive parenting intervention.

Do the core components of PCIT meet the needs of Latina/o families for a preventive parenting program?

Participants held favorable views toward specific PCIT components such as didactic sessions and live coaching during parent-child interactions as well as behavior modification techniques such as ignoring minor misbehavior, praising positive behavior, and giving effective commands. Results also suggest that many of the principles underlying PCIT, such as the importance of consistency, limits, and obeying, are not uncommon among U.S. Latina/o parents. In fact, many of the practices that are coached in PCIT appear consonant with parents’ understanding of effective parenting. For instance, parents identified positive attention towards children as important in modifying behavior and healthy development, a belief that is consistent with the model of parenting undergirding PCIT. As a whole, results suggest that many of the core features of PCIT are acceptable to the Latina/o parents who participated in our research.

Nevertheless, parents were ambivalent or unsure about some of the characteristic features of PCIT. While time-out was viewed favorably by some parents, others discussed how it is not a prevalent discipline strategy in many Latin American countries. In vivo coaching, which is a core feature of PCIT, also drew mixed responses from parents. Although these findings are important, it should be noted that concerns about time-out and in vivo coaching are also common among non-Latina/o parents first introduced to PCIT, and that these concerns tend to lessen as parents progress through treatment (McCabe & Yeh, 2009). An effective preventive parenting program should take care to present these components in ways that are culturally-responsive to Latinas/os.

How can PCIT be tailored to work efficiently and effectively as a preventive program within the community?

The themes offered by Latina parents will help to shape the development of a PCIT prevention model that is culturally responsive and contextually grounded. As supported by previous research, our investigation revealed that many aspects of PCIT appear compatible with Latina/o culture and will not require modification in the prevention model: for instance, an emphasis on the importance of parental authority and the value of including extended family members in the intervention (McCabe et al., 2005). Further, parent responses to core components of PCIT, such as in vivo coaching, were generally positive and not considered necessary to alter. This finding is also consistent with adaptation research on the treatment intervention (McCabe et al., 2005; McCabe & Yeh, 2009).

Based on our findings, however, some changes in the delivery of PCIT appear indicated to improve the responsiveness of a preventive parenting program to a Latina/o community. First, and perhaps most obviously, participants suggested that any program would have to be available in both English and Spanish. Many parents also expressed preference for a prevention program delivered in a group format, which is consistent with some adaptation research on parenting interventions for Latina/o families (Parra-Cardona et al., 2009). Group formats of PCIT have demonstrated efficacy with clinical, non-Latina/o families (Niec, et al., 2013); thus, this format may offer a feasible adaptation. An interesting potential addition to the PCIT prevention model that was recommended by families in this study is the use of informational, pre-program group meetings designed to raise interest and provide families with the opportunity to engage with group leaders and potential participants before the program begins.

Finally, earlier adaptation research of PCIT for Latina/o families did not intend to consider alternate delivery levels (i.e., prevention) and thus did not consider providers other than traditional mental health professionals. It was of primary interest in this study to determine whether US Latina/o families would perceive natural helpers as acceptable as leaders of a parenting program. Consistent with the literature on help-seeking patterns among U.S. Latinas/os (Alegría et al, 2004), participants identified a broad range of individuals who could best serve as preventionists. Although some parents included the licensed mental health professionals, most parents expressed preferring to receive help from community members including teachers, day care providers, nurses, and people involved in religious ministry—in other words, individuals who are considered natural helpers. Because some evidence demonstrates that natural helpers may be successfully trained as parenting coaches (e.g, Calzada et al, 2005), the potential for incorporating natural helpers as parenting preventionists in Latina/o communities warrants further consideration (Acevedo-Polakovich et al., 2013).

Limitations

Current findings should be considered in the context of the study’s limitations. This study identifies factors relevant among U.S. Latina/o parents in one community. Although this ensures that our findings are directly relevant to the community for which we wish to adapt an intervention, the degree to which our findings generalize to other groups of U.S. Latina/o parents is unknown and is an important direction for future research (LeCompte & Goetz, 1982). Additionally, from a CAP framework, this study represents the first step in the lengthy process of adaptation and evaluation of a promising preventive intervention. Current findings are best interpreted as hypotheses amenable to future testing.

Conclusions

Taken together, findings suggest that—with adequate consideration of cultural and community factors—PCIT may be an appropriate foundation for the development of a preventive parenting intervention that can address the needs of U.S. Latina/o families. Our results point to important factors that will need to be considered. These include specific cultural values (e.g., respeto), specific community needs (e.g., the effects of immigration and acculturation upon family functioning), and potential adaptations to the delivery of the intervention (e.g., a group delivery format, delivery by trained community preventionists). Each of these factors can potentially aid in the resolution of service disparities. The documented unmet needs of U.S. Latina families, and the experiences of the parents involved in our research, suggest the research cannot come soon enough.