A Balancing Act: Integrating Evidence-based Knowledge and Cultural Relevance in a Program of Prevention Parenting Research with Latino/a Immigrants

Widespread mental health disparities continue to impact underserved ethnic minority populations throughout the United States (SAHMSA, 2015). Precursors of these disparities include significant access barriers to efficacious and culturally relevant mental health services (e.g., high cost of services, fear of discrimination). With the recent passage of the Affordable Care Act of 2010, family therapists have a unique opportunity to address these gaps in service delivery and research. For example, there is a pressing need for culturally adapted prevention parenting interventions aimed at reaching diverse families before they experience a variety of relationship difficulties (Baker, Arnold, & Meagher, 2011).

Our program of prevention research is responsive to calls by scholars to demonstrate the impact of culturally relevant mental health services for underserved minority populations (Alegría, Atkins, Farmer, Slaton, & Stelk, 2010). Thus, the primary objective of the current qualitative investigation was to compare and contrast the perceived relevance of two culturally adapted versions of the efficacious parenting intervention known as Parent Management Training, the Oregon Model (PMTO^R). This qualitative study is embedded within a larger program of research funded by the National Institute of Mental Health (NIMH), focused on empirically testing the differential efficacy of the two culturally adapted interventions. In this article, we describe the level of acceptability of the two differentially culturally adapted interventions according to first-person accounts provided by 112 Latino/a immigrant parents.

Cultural Adaptation

Substantial empirical research indicates that underserved ethnic minority populations can benefit from culturally adapted interventions (Barrera, Castro, Strycker, & Toobert, 2013; Martinez & Eddy, 2005; Smith, Domenech Rodríguez, & Bernal, 2011). However, in order to be effective, adapted interventions must ensure a close fit with the cultural values and experiences of target populations (Castro, Barrera, & Martinez, 2004). Further, cultural adaptation scholars emphasize the need for studies aimed at clarifying which specific components of adapted interventions, as well as methods of intervention delivery, are perceived as most relevant by the recipients of interventions (Castro, Barrera, & Holleran Steiker, 2010). There is also a scarcity of qualitative studies focused on describing first-person accounts of ethnic minority parents’ perceived satisfaction with adapted interventions (Piquero, Farrington, Welsh, Tremblay, & Jennings, 2009).

Parent Training Interventions

Parent Training (PT) consists of the use of didactic and applied instruction and behavior modeling for effectively managing child behavioral problems (Martinez & Eddy, 2005). The positive impact of PT interventions for the treatment of child conduct problems has been thoroughly documented in research in real-world settings (Lundahl, Nimer, & Parsons, 2006; Michelson, Davenport, Dretzke, Barlow, & Day, 2013). Meta-analytical studies have identified core parenting components commonly associated with efficacious PT interventions (Kaminski, Valle, Filene, & Boyle, 2008; Lundahl et al., 2006; Piquero et al., 2009). Components identified as having the highest impact include the promotion of positive parent-child interactions, encouragement skills, emotional regulation, communication, and non-corporal limit setting practices. Meta-analytic data also indicate that the most effective parenting programs are characterized by a strong focus on behavior modification (Kaminski et al., 2008).

Although the impact of PT interventions has been empirically demonstrated, there is still a high need for studies aimed at clarifying the specific PT components that are likely to increase perceived relevance and satisfaction among diverse populations (Baker et al., 2011). This will help in disseminating PT programs not only to more diverse families already experiencing child conduct problems, but preventatively to families who are not (or not yet) experiencing such difficulties. However, disseminating PT interventions as preventative programs must include addressing unique challenges, such as parents not perceiving a need for parent training if their children do not exhibit internalizing or externalizing behaviors (Baker et al., 2011; Kaminski et al., 2008; Piquero et al., 2009). Additional contextual barriers for engagement and retention of ethnic minorities include poverty, lack of cultural fit with interventions, and fear of discrimination (Bjørkness & Manger, 2013).

The current manuscript describes the level of acceptability of two differentially culturally adapted parenting interventions as reported by a group of predominantly low-income Latino/a immigrant families. This research was informed by the specifications of prevention research and intervention delineated by the National Research Council and the Institute of Medicine (O’Connell, Boat, & Warner, 2009). Specifically, we targeted underserved Latino immigrant families with children exhibiting mild to moderate problem behaviors. Our work centers on the expectation that, by helping parents strengthen their childrearing practices, families will be able to prevent the onset of child mental health disorders and family conflicts commonly associated with ineffective and harsh parenting practices.

Method

Participant Characteristics

Participating Latino/a families had a target child (TC) between 5 and 12 years of age who exhibited mild to moderate behavioral problems. This age range resembles the developmental range of previous PMTO studies. Components and intervention materials were focused on the needs and experiences of families with children within this age range. Families with children that exceeded the behavioral problems criteria were referred to our community partners for mental health services. All participating parents had to self-identify as Latino(a)/Hispanic and be Spanish-dominant speaking. Children could be Spanish- or English-dominant. The majority of participants across all intervention conditions (90.4%, n = 171) were of Mexican origin, with the rest (9.6%, n = 18) reporting Honduras, Guatemala, and Colombia as their countries of origin. The majority of families also reported exposure to considerable financial challenges. There were no condition differences on parent age or number of years living in the US. The detailed characteristics of participants are presented in Table 1.

Table 1.

Participants’ demographic information

	CAPAS (CA)	CAPAS-Enhanced (CE)	Control Group
Family Characteristics
Participating Families	36	35	32
Annual Family Income
$10,000–20,000	41.7%	22.9%	25.0%
$21,000–30,000	25.0%	34.3%	37.5%
$31,000–40,000	11.1%	22.9%	15.6%
Greater than $40,000	13.9%	11.4%	12.5%
Average Number of Children in Householda	2.69 (±0.98)	2.63 (±1.11)	3.10 (±1.08)
Average Age of Childrena	9.44 (±3.35)	8.66 (±2.85)	9.16 (±3.18)
Individual Characteristics
Participating Individuals	66	64	59
Mothers	36	35	32
Fathers	30	29	27
Country of Origin
Mexico	59	57	55
Average Parent Agea	35.97 (±4.83)	36.97 (±6.48)	36.52 (±5.29)
Average Years Living in USa	15.04 (±4.88)	14.11 (±5.48)	14.80 (±5.72)
Average Years of Educationa	9.38 (±3.08)	8.72 (±3.28)	7.87 (±2.48)

MANOVA results

^aF(10, 174) = 0.843, p = .588; Wilk’s Λ = .910, partial η² = .038.

Sampling Procedures

Participants were recruited by posting flyers in churches, health care settings, and mental health offices. Recruitment was also conducted at important community events and cultural festivals, as well as word-of-mouth referrals from parents who had previously completed the intervention. Families were screened according to Bird and colleagues’ (2001) screening instrument of child externalizing behaviors.

Qualitative data were collected through focus groups interviews implemented after the completion of each wave of parenting groups. Only participants who completed at least 6 sessions of either the CAPAS (CA) or CAPAS-Enhanced (CE) program were included in the interviews (n = 112). All focus group interviews were audio recorded and transcribed for data analysis. None of the interventionists were present at the focus groups interviews. A total of eight focus groups were conducted in Spanish with 12–16 parents per group, each lasting between 60–80 min. All interviews were completed at the implementation site. Because this was a comparative study, participants were exposed to one of two versions of the culturally adapted PMTO intervention (i.e., CA vs. CE). The two adapted interventions were offered across four waves of parenting groups, for a total of eight parenting groups.

Participants were individually compensated for their participation in each assessment of the randomized design (i.e., baseline $30, intervention completion $40, 6-month follow-up $50). This study received approval from the corresponding Institutional Review Board (IRB).

Measures

Demographic information included individual characteristics of family members, combined annual family income, number of children living in the household, and country of origin. Participants also completed a session satisfaction questionnaire on a weekly basis to measure level of satisfaction with each parenting session according to a Likert-type scale that ranged from 1 (not at all satisfied) to 5 (very much) (Forgatch et al., 2009).

Focus group interviews followed a semi-structured interview guide which began with an open-ended question asking participants to identify the intervention components they experienced as having the most impact on their parenting practices. Follow-up probes on specific components not addressed by participants in the initial open-ended question were also asked and the relevance of these responses for participants was noted. A detailed description of the focus group protocol, including the interview guide, is available from the first author.

Research Design

Differential research designs in cultural adaptation allow for the identification of differential impact of intervention components in a way that cannot be examined in designs comparing an adapted intervention to a control condition (Castro et al., 2010). Thus, following a pilot study aimed at culturally refining intervention materials and study procedures (Author, 2012), participants were randomly assigned to either: (a) CA, (b) CE, or (c) wait-list control group.

Interventions

PMTO^R was selected as the foundation of our program of research because studies have indicated a close cultural fit between the core PMTO components and salient cultural values and parenting experiences of Latino parents (Author, 2012; Domenech Rodríguez, Baumann, & Schwartz, 2011). Further, the theoretical and empirical foundations of this intervention established a mediational model as the source of child behavioral improvement. That is, in contrast to family therapy models that emphasize the need for interventionists to work directly with all family members, parents are the primary focus of the PMTO intervention as enhancing the quality of their parenting practices has been consistently associated with sustained reductions of child internalizing and externalizing behaviors (Forgatch, Patterson, DeGarmo, & Beldavs, 2009).

CAPAS (CA). The first cultural adaptation of the PMTO intervention for Latino immigrant populations was conducted by Dr. Domenech Rodríguez and colleagues with funding support provided by NIMH. Two core components (i.e., monitoring and family problem solving) were translated and adapted by researchers conducting PMTO implementation in Mexico (Authors, 2014). The Spanish version of the PMTO intervention was titled “CAPAS: Criando con Amor, Promoviendo Armonía y Superación” (Raising Children with Love, Promoting Harmony and Self-Improvement; see Domenech Rodríguez et al., 2011). The research was guided by the Cultural Adaptation Process Model (Domenech-Rodríguez & Wieling, 2004) and the specific manual adaptation followed the tenets of the Ecological Validity Model (EVM; Bernal, Bonilla, & Bellido, 1995). The EVM model specifies adaptations according to the following dimensions: (a) language, (b) persons, (c) metaphors, (d) content, (e) concepts, (f) goals, (g) methods, and (h) context. The initial development of the CA intervention consisted of a lengthy process, as adaptation considerations were carefully examined and implemented according to all the levels of the EVM model. For example, cultural experts and consultants were asked to carefully examine the intervention manual and supportive materials to ensure linguistic appropriateness and cultural relevance (i.e., dimensions of language and content). Cultural expressions were included in the adaptation of role play scripts (i.e. dimensions of methods and language). Thus, although CA consists exclusively of the core PMTO components, the level of adaptation was rigorous at all the levels indicated by the EVM.

CA consists exclusively of the adapted core components of the original PMTO intervention, which are: (a) positive involvement (i.e., promoting nurturing relationships with children), (b) skills encouragement (i.e., helping children to develop skills aimed at developing self-sufficient behaviors), (c) limit setting (i.e., mild discipline strategies), (d) monitoring and supervision, and (e) family problem solving.

CAPAS-Enhanced (CE)

This intervention consists of all the components of the CA curriculum plus two culture-specific sessions focused on addressing cultural themes that were identified as relevant by participants in an exploratory study (i.e., immigration challenges, biculturalism). The CE intervention also included brief reflections included at the beginning of core PMTO components session, highlighting the cultural relevance of each specific PMTO parenting practice (see Author, 2012).

Interventionists and training

Two teams delivered the adapted interventions. Each team was integrated by a female master’s level clinical social worker and a male professional from a university extension unit with a background in community organizing.¹ All interventionists were Latinos/as, fully bilingual, and residents of the community in which the interventions were delivered. Two 5-day intensive trainings were led by the first and third author, followed by 1-day booster training at the completion of the pilot study. The first author is a PMTO certified specialist and fidelity rater. The third author is a PMTO Mentor. To ensure fidelity to the core PMTO components, live and video supervision was provided to interventionists by the first author. The first author was in turn closely supported via video-conferencing by one of the original developers of PMTO.

Analytical Strategy

Descriptive analyses were conducted to analyze levels of attendance and satisfaction with individual intervention components. A thematic analysis (TA) approach was implemented to analyze qualitative data gathered through focus groups (Braun & Clarke, 2006). The first and second authors coded the data independently, achieving high interrater agreement across all individual codes (percentage agreement range: 92.3% – 99.4%; Cohen’s Kappa range: .65 – .99). These Kappa values indicate a range from good (.61 – .80) to excellent (.81 – 1.00) agreement. Differences between coders were discussed until consensus was reached. The initial results were shared for consistency with the third author. An audit trail and journaling were also used to increase the trustworthiness of the data. Trustworthiness in qualitative research refers to the methodological provisions that are implemented to ensure rigorous analytical procedures (Morgan, 1997). All data analyses were conducted in Spanish utilizing NVivo version 10.0 software.

Results

Retention

High retention was achieved in both adapted interventions. Regarding family units, 32 families (87.8%) randomly assigned to CA completed a minimum of 6 out of 12 sessions, compared to 31 families allocated to the CE intervention (88.5%). Remaining families in both conditions completed 1–3 sessions. The overall retention of fathers at intervention completion was also high (87.2%).

Intervention Satisfaction

High levels of participant satisfaction were reported in both interventions. Aggregated weekly satisfaction ratings across all sessions averaged 4.52 in the CA intervention (SD = 0.06, range: 4.50–4.61) and 4.57 in the CE intervention (SD = 0.05, range: 4.48–4.68). With the exception of wave 4 (α = .67), internal consistency coefficients ranged from α = .87 to α = .89 across all waves. No significant session satisfaction differences were found between interventions on any of the individual sessions focused on the PMTO core components. Similarly, there was not a significant difference in overall satisfaction between interventions across all four waves of the study, t (128) = −.67, p = .53, d = 0.55. No differences based on parent sex were calculated, as the satisfaction forms were anonymous and did not ask for this information. The overall high satisfaction with both adapted interventions was confirmed through in-depth qualitative reports.

Focus Group Findings

Participants discussed their perceptions of the relevance of core PMTO components, PMTO intervention delivery/teaching tools, the role of interventionists, and culture-specific components of the interventions (see Table 2 for coding specifics). Coded categories indicate: (a) the number of focus groups in which each coded element was discussed through detailed narratives, and (b) the percentages of participants’ narratives addressing each coded theme. Participant statements were coded only if participants’ narratives were clearly identified. We followed reporting procedures customary in qualitative studies conducted with audio-recorded focus groups data (Morgan, 1997).

Table 2.

Coding percentages of selected themes included in the Thematic Analysis

PMTO Core Components	CAPAS-Original Focus Groups in which themes were addressed(N=4)	CAPAS-Original Individual Quotes (N= 79)	CAPAS-Enhanced Focus Groups in which themes were addressed(N=4)	CAPAS-Enhanced Individual Quotes (N= 81)
Positive Involvement	4	23 (29.1%)*	4	32 (39.5%)*
Limit Setting	4	16 (20.2%)	4	18 (22.2%)
Skills Encouragement
Skills encouragement Useful	4	17 (21.5%)	4	13 (16%)
Skills encouragement not Useful	1	2 (2.5%)	0	0
Monitoring and Supervision	4	15 (18.9%)	4	13 (16%)
Family Problem Solving	3	6 (7.5%)	3	5 (6.2%)
Additional Skills/Teaching Tools	Focus Groups (N = 4)	Individual Quotes (N= 52)	Focus Groups (N =4)	Individual Quotes(N= 41)
Emotional Regulation	4	16 (30.7%)	4	11 (26.8%)
Good Directions	4	12 (23%)	4	15 (36.5%)
Role Plays
Useful	4	19 (36.5%)*	4	12 (29.2%)*
Not useful	1	5 (9.6%)	2	3 (7.3%)
Role of Interventionists	Focus Groups (N =4)	Individual Quotes	Focus Groups (N =4)	IndividualQuotes
Positive role of interventionists	4	20	4	23
Culture-specific Components	Focus Groups (N = 0)	Individual Quotes (N=0)	Focus Groups (N =4)	Individual Quotes(N=48)
Immigration	N/A	N/A	4	25 (52.0%)
Biculturalism	N/A	N/A	4	23 (47.9%)

^*The column % do not sum to 100% due to rounding.

PMTO core components

Positive involvement

Positive involvement was the component identified as most relevant by participants in both the CA and CE interventions. Positive involvement refers to parenting skills aimed at increasing warmth and nurturing relationships with children. For example, parents discussed the need to change their behaviors and expectations towards their children, as one mother (CA) expressed, “I learned that I was the one who had to change, rather than expecting my child to change. Before, my son would approach me and I would evade him. Now, he approaches me and I express my love to him.” Parents also emphasized the importance of openly expressing affection to their children. A mother (CE) affirmed:

What I learned in this class is something that I was never told when I was a kid. I wished my parents had told me that they loved me. Now I get closer to my kids and tell them that I love them. Because I did not live this as a kid, I was not expressing it to my children.

By experiencing a new way of relating to their children, parents reported important changes in the quality of family relations, as one father (CA) affirmed, “the group was helpful because we changed our attitude at home. We do not yell at our children anymore, as we used to in the past.” According to participants, a key step towards improving the relationship with their children consisted of recognizing their children’s strengths. One mother (CE) stated, “Group helped me to open my eyes. I learned to recognize the good things about my daughter. This was hard for me because I used to only see what she did wrong and I would criticize her.”

Spending more quality time with children was also a noticeable change reported by parents. One mother (CA) said, “Now I talk more with my daughter and spend more time with her. I was not having enough time with her and I learned to organize things in my life so I can enjoy more time with her.”

Parents also reported self-awareness with regards to how the relationship with their children was influenced by cumulative stress. One mother (CA) stated, “my daughter used to tell me, ‘you are always working and I want to play with you and share time together.’ Now, I have found a way to spend more time with her.” In general, parents reported that this intervention component helped them to improve the quality of relationship with their children, as one mother (CE) affirmed:

I was not close to my children and would not ask for things with good manners. I would only yell at them, “Do this!” “Do that!” And I learned here that one thing is respect and another fear…they were afraid of me. I am much closer to them now.

Limit setting

Learning new ways to discipline children was the second most relevant component to parents. An interesting sex effect was identified in the data. Specifically, fathers reported the positive impact of the intervention as they admitted frequently engaging in harsh parenting practices resulting from getting home late from work and trying to discipline children. In contrast, mothers more frequently than fathers reported their children being withdrawn and sad, reactions that they attributed to what they referred as constant “nagging” by them in their efforts to implement discipline, as well as deficient limit setting skills. For example, one mother (CE) reported her ineffective use of time-outs, “Before, I would put my children in time out but because I did not know how to do it, I would put them in time out for 20–30 minutes…It depended on how angry I was.”

According to the PMTO model, if time outs are not effective, parents can remove a privilege. Privilege removal consists of not allowing children to experience a routine or activity that is pleasurable but not central to their development (e.g., not watching their favorite cartoon for one night). One father (CE) reflected on the usefulness of this technique, which captured reports by parents emphasizing their satisfaction with being able to implement non-punitive limiting setting practices:

What helped me the most was to learn how to use privilege removal. Before, we thought that the more time you removed the privilege, the better. But no, we learned here that it should be a short time as children should know they can have it back.

Monitoring and supervision

Participants uniformly reacted positively towards the component focused on monitoring and supervision. One mother (CA) affirmed, “Now, I am checking on my kid every half an hour. I’m always asking myself, ‘Where are they?’ ‘Who are they with?’ ‘What are they doing?’ I learned that I need to supervise them at all times.” Similarly, another mother (CE) said, “We were missing some things. Like knowing very well who his friends are and making sure he knows phone numbers from all of us.” Parents also reflected on how the interventionists motivated them to refine their monitoring practices in external settings. One father (CE) affirmed:

I was one of those persons that would only take my daughter to school, drop her off, and leave her there. Now, I go in and talk with the teachers and I have improved on this because I want to be closer to my daughter, even if I do not speak English well.

Skills encouragement

The last core PMTO component identified as relevant by parents across all focus groups referred to skills encouragement. Through skills encouragement parents help youngsters master a variety of behaviors that will help them gain self-sufficiency. One father (CE) described an insight commonly shared by other parents, “I realized that children need incentives to feel motivated and do things better. Just like we ask for a salary raise, and we do things better with a raise, children need incentives.”

Incentive charts are a tool that promotes building complex skills by breaking down complex behaviors (e.g., cleaning the bedroom) into manageable steps (e.g., making the bed, putting dirty clothes in hamper). Across all groups, participants provided narratives illustrating the usefulness of implementing charts, as one mother (CA) reported, “The incentive chart helped me a lot. I was always stressed about getting my daughter to school on time. Now, we get up early and she does everything that is written in the chart. It is helping a lot.” A father (CE) provided a similar reflection, “I liked the chart with the five steps a lot. I always had problems with my daughter doing her homework. From giving 25 orders at once, now it is only five steps. It has helped me a lot.”

Some parents described challenges with the principles underlying skills encouragement techniques but eventually embraced the technique. Specifically, some participants believed that children should not be consistently rewarded for good behaviors. One mother (CA) illustrated the dilemma shared by other parents, “Learning this was hard for me because I assumed that it was enough to only scold my children…I would not speak to them for hours if I was angry at them. I have worked hard at changing this.”

Not all parents implemented all of the techniques taught in the class. For example, two fathers in one group reported that the skills building intervention component were not relevant to their parenting practices as they considered that children should not expect to be consistently rewarded for daily good behavior. The first participant (CA) affirmed:

I never agreed with describing the incentive charts to children, because they will manipulate you to obtain things. I did not tell my daughter about the incentive chart or the rewards. I found a way to reward her spiritually and it has worked for me.

Similarly, the second father (CA) stated, “Children learn to manipulate with the incentive chart. I think there should be a way to present the table in a different way.”

Family problem solving

Parents in six groups reported that family problem solving skills were useful to their parenting practices. One (CE) father reported, “We benefited a lot from the family meeting. We never did it before and we never let children express their opinions. Now, we are holding our family meeting once per month and it has brought us together.”

Participants also expressed that the intervention promoted family cohesion while solving problems. A mother (CA) illustrated this issue, “we had meetings but only to make financial decisions. We learned in the group that we could do it in a different way. Now, we have signed our family contract and we remind each other, ‘We signed a contract, remember?’” Parents who implemented these skills reported improved family communication, as one father (CA) said, “This is a very useful tool because we let children know that their opinion matters and that they are important when we make decisions as a family. This promotes family unity a lot.” One father (CE) expanded on these issues:

I was the youngest child and my parents always focused on the oldest children. That affected my self-esteem. I would say to myself “I’m not good enough” “What I do is not good enough.” Now we apply this program with my children by involving our youngest daughter and she says, “Wow, you are taking me into consideration!”… “Not only my sister who does things better, but I also matter here.”

Additional skills/ teaching tools. In addition to identifying core components of the parenting interventions that resonated with them, families noted specific skills they found helpful to implement. The two most salient were learning how to regulate their emotions, and learning how to give good directions.

Emotional regulation

The ability to gain emotional regulation was reported as relevant by parents in all focus groups, particularly if they had experienced child abuse or neglect as children. One father (CE) affirmed:

I suffered a lot of physical abuse from my parents because they hit me a lot. Then, I became very impulsive towards my children. This program was not for my daughter but for me, as I am the one who has benefited the most. I am grateful because although my parents did not have this, I did, and now my children will benefit a lot.

Parents described how harsh parenting practices were associated with their limited ability to regulate emotions. For these parents, the intervention had a positive effect, as one father (CA) affirmed, “whenever my child talked back to me, I would get infuriated, and I would grab him and yell at him, ‘I told you to do so!’ Here we learned to control ourselves and I have improved a lot.” Finally, parents reported that a common practice was to yell at children rather than managing difficult situations in a calm way. One father (CA) illustrated a common dilemma shared by other parents, “I used to yell and expect my children to comply. Yelling was my way of reacting. Now, I have learned with these tools to control my emotions, to breathe, and to control myself.”

Giving good directions

Parents in all focus groups provided detailed narratives describing the usefulness of learning to give good directions to children, which in PMTO constitutes a foundational parenting skill. One mother (CA) described the benefits she experienced from practicing how to give good directions:

Learning to give good directions has helped me a lot. Before, I would ask her to do many things and she would not do anything. Now, I give her a specific instruction, she understands it, and follows through. Our conflicts have diminished a lot.

Parents also emphasized how this skill prevented parent-child escalations, as one mother (CE) reported, “I benefited from learning how to give directions. I was always angry when giving directions and because I had to give directions two or three times, my children would not comply. Now, I first have emotional control and then I give directions and everything is better.

Role plays

Many expressed that the use of role plays helped them gain empathy for their children, recognize harsh parenting practices, and master new parenting skills. One father’s feedback (CE) resembled reflections shared by other parents, “when I was in the role of a child, I was like ‘wow!... This is the way my children feel when I yell like this.’ I could feel the tension that my child feels.” A mother (CA) stated:

Role plays helped me to feel how my children feel…Whenever I yell at them, or nag them by saying to them, “Why did you do it?! [child misbehavior], Why did you do it?!... You are dumb!”… These role plays helped me to stop saying this because they helped me to understand how my children feel.

Parents also reported that role plays allowed them to improve parenting skills by regulating their emotions, as one mother (CE) affirmed, “I have a short temper and when my kids make me angry, I just explode. I practiced these situations in role plays and learned to control myself. Role plays helped me lot.”

Although the majority of families appreciated the use of role plays to practice new skills and gain new insights, eight parents in three groups provided narratives indicating that role plays were not useful to them. Six of the narratives were provided by fathers and among the reasons cited, participants reported that they felt uncomfortable doing role plays with people they did not know and that role plays were not realistic. One father (CE) noted, “I felt uncomfortable with the role plays because we were asked to do them with people we did not know.” Similarly, another father (CA) stated, “How am I going to pretend that it is real what we do in the role plays, compared to what takes place at home?” One father (CA) expressed a similar criticism, “it is very different to be with your kid than doing a role play with an adult who does not react like your kid. Role plays were not useful because they were not real.” Finally, a mother (CE) reported that role plays were boring to her, “Role plays were boring to me. When I was asked to act like a kid, I was like, ‘no, I don’t like that.’”

Role of interventionists

According to participants, the most important interventionists’ qualities consisted of their ability to engage parents in genuine ways, their expertise of the intervention, having a good sense of humor, and their ability to frame the parenting skills within relevant cultural experiences and values. One mother (CA) affirmed, “The interventionists never left us with any doubts. I saw a lot of dedication from them and they never ignored us. They were excellent, always accessible to everyone, very cordial, and friendly. They were always concerned about us.”

A father (CE) elaborated on the importance of interventionists’ expertise: “they know the program very well. They never hesitated when they were presenting a theme. They know exactly what they are doing and knew how to respond to all the examples that we presented to them.” A father (CA) further elaborated on an issue commonly discussed among parents, “the topics are very relevant but without these interventionists, they would not have been as relevant as they were. They knew how to present it to us as Latinos. Even with a good program, without good facilitators, the program will not work. Thanks to them, the program was excellent.”

The interventionists’ patience and caring attitude was commonly highlighted by participants, as one father (CA) affirmed, “I liked their patience and how they talked to us. They had a lot of patience with us and were very caring.” Finally, parents reported the value of interventionists sharing their own personal experiences. One mother (CE) summarized the participants’ feedback on this issue:

What I love about them [interventionists] was that they talked about their own experiences. That helped a lot because sometimes, I felt like things were not going well and then you heard about how they also struggled. So, for me, it was very important to hear their own experiences, because they had lived what we were living in the program.

Culture-specific sessions

Participants exposed to the CE intervention reflected about the relevance of culture-specific sessions, which focused on addressing cultural themes (i.e., immigration and biculturalism) that had a direct impact on their parenting practices.

Immigration: Challenges and Benefits

Parents described in detail multiple challenges associated with being first-generation immigrants. One mother discussed challenges reported by the majority of participants in the CE groups:

You grow as a person by being an immigrant. You also struggle if you do not have basic services such as health insurance. Without an education, you cannot grow professionally in this country. It was important for me being able to talk with other parents about the limitations we experience in this country as immigrants.

Fear of prejudice and discrimination was also consistently reported by parents. One mother stated:

My neighbors starting calling my daughter “little Black girl”…and then she started dating a White boy who would say to her “you are not Black, you are Brownish.” This is hard…I just wish we all could teach our children that we can live without being racists to one another.

In contrast to perceived challenges, parents highlighted multiple benefits associated with being an immigrant. One participant summarized the thoughts shared by many participants:

We are grateful for the many resources that we have here and that we do not have back in our country. Our children have many opportunities like the education they are receiving and we are able to have medical care, which would be difficult to obtain in our country. We also learn in this country to be with people from many cultures. It is about getting to know different cultures and learning to appreciate this opportunity.

Becoming a Bicultural Family

Parents repeatedly discussed the challenges associated with their children adopting cultural values and traditions that contrasted with theirs, as well as the difficulties of trying to promote the Latino/a culture with their children. One father affirmed:

It is hard to practice our traditions in this country. Society slowly takes you away from these traditions. It is not the same talking to our children about our traditions than to be in our countries where our traditions are taking place. However, we do not have the means to take them to our country for our children to experience our values and celebrations.

A mother also expressed a sense of loss commonly shared by other parents:

I thought that my children were going to grow and think like I do, as a Mexican. But then I realized that they are growing up here... Their minds are different. If I only teach them what I learned in Mexico, I will not offer them a good education. I need to learn how to raise them in a new way by also adapting to this culture.

Parents also discussed the importance of talking in group about ways to become bicultural families. One mother stated:

As a parent, we have to accept our children’s world. We need to accept the traditions that our children are experiencing in this country but we also need to get deep into our children’s lives and teach them how to integrate our traditions… Whatever is good from this country and what we know is good about our own country.

A parent elaborated on the process of gradual acceptance associated with becoming a bicultural family, an experienced frequently shared by other participants:

It has been difficult for me to accept that my children are half Mexican and half American. But I have learned that I cannot take away from them this culture and that they cannot take away from me my own culture. I’m slowly learning this and how to adapt to this reality. They have a right to choose what they like from the American culture and what they like from our Latino culture.

The importance of parents acting as cultural brokers for children was emphasized by the majority of participants, as one father affirmed:

We have Latino roots but we need to know that our children are not familiar with our values. We need to explain this to them and help them to integrate traditions from both countries so they can feel they belong to two cultures. We need to teach them to respect the traditions of other cultures by learning to value of their own traditions.

Finally, parents discussed the importance of biculturalism as a way to prepare their children for the future. One mother expressed a thought that was repeatedly addressed by other parents:

Although there are many challenges, living in this country also brings to our children’s lives many opportunities. We need to teach our children how to choose good values and recognize the opportunities they have here, like being bilingual and knowing other cultures…We also have to make sure that they adapt to our culture. We need to help them to live between two cultures, because by having two cultures, they will have many opportunities in life.

Discussion

This study constitutes a contribution to the field by offering Latino/a parents’ narratives of their perceived relevance of two culturally adapted interventions. Specifically, participants’ first-person accounts described the parenting intervention components that were relevant to them, the specific PMTO parenting skills they chose to use (and which they did not), how culturally relevant they found the adapted interventions, and how they considered their new parenting skills are changing their children’s behaviors and parenting dynamics.

Perceived Relevance of Core Parent Training Components

Concurrent with aggregated quantitative reports of high satisfaction with PMTO sessions across all cohorts in both intervention conditions (i.e., CA, CE), the majority of participants reported PT components as useful to their parenting practices. These findings confirm previous PMTO studies indicating that the intervention’s core parenting components are culturally syntonic with Latino/a immigrant populations (Author, 2012; Domenech Rodríguez et al., 2011). According to frequencies of mention of qualitative narratives, parents identified positive involvement, limit setting, skills encouragement, and monitoring and supervision as particularly relevant. Current results also aligned with previous research findings indicating that two foundational skills (emotional regulation and giving good directions) were also perceived as useful by parents. These skills have been found to be associated with long-term positive changes in parenting skills (Bjørkness & Manger, 2013). Although qualitative reports associated with the problem solving component illustrate the importance of this parenting skill, this component was not identified as prominent by all participants across all groups. Because family problem solving has been found to be critical to outcomes 9-years post-PMTO intervention (Forgatch et al., 2009), these findings indicate the need to evaluate whether the current approach to teaching problem solving is the most appropriate for the population under study.

A minority of parents expressed that they did not experience the skills encouragement component and role plays as relevant to their parenting practices. This information is important as fit between intervention components and the participants’ values and worldviews must be continually monitored (Bernal & Sáez-Santiago, 2006). Although these findings do not necessarily warrant the modification of the core components under study, as they proved to be beneficial for the majority of participants, data highlight the need to closely monitor the intervention delivery process to rapidly identify the ways in which content or intervention delivery approaches may not be syntonic with cultural values and beliefs of a subset of research participants (Castro et al., 2010).

Data also highlight the need to further investigate the key role of interventionists as cultural brokers, a term originally proposed by Spiegel (1972). While parents noted the importance of interventionists’ general knowledge, warmth, sense of humor, and expertise; they also spoke of their ability to frame information according to the participants’ most relevant cultural experiences and values. The interventionists in this study were fully bilingual and Latino/a. The extent to which their acceptance by families was due to this shared identity versus their overall parenting knowledge and skills deserves further study.

The Relevance of Culture

The original adaptation of the PMTO intervention (i.e., CAPAS) was implemented according to a rigorous model of cultural adaptation (Domenech Rodríguez et al., 2011). The CE intervention consisted of an enhanced version of the CAPAS intervention which included culture-specific sessions as well as cultural framing prior to the introduction of each core PMTO component. These adaptations were grounded in a comprehensive qualitative study (n = 83) aimed at identifying salient cultural experiences impacting the parenting practices of Latinos/as in the target population. According to the correspondence of quantitative indicators of satisfaction and qualitative narratives, current findings suggest that a multi-dimensional and rigorous process of adaptation is likely to be associated with increased participant satisfaction and perceived relevance with adapted components (Barrera et al., 2013).

In addition, parents randomly assigned to the CE intervention consistently reported the relevance of the culture-specific sessions, which allowed them to process the impact of immigration, contextual adversity, and biculturalism on their parenting practices. These findings correspond with the aggregated quantitative reports of high satisfaction with culture-specific sessions across all CE parenting cohorts. Furthermore, parents exposed to the CE intervention indicated a need to expand the discussion focused on culture-specific themes, particularly those that refer to negotiating two contrasting cultural orientations among family members. These findings confirm the relevance of existing efficacious interventions that have adopted biculturalism as a core component in preventive and clinical interventions with Latino/a immigrant families (Martinez & Eddy, 2005; Smokowski, David-Ferdon, & Bacallao, 2009; Perrino et al., 2014).

Limitations of the Study

This study has a number of limitations to be considered. First, narratives were likely to be provided by the parents who felt most comfortable in the focus group settings, a factor that could have significantly reduced the willingness for participants with dissenting opinions to disclose their personal views. The timing of data collection may have been influenced by recall bias, particularly because data were collected at intervention completion and participants may have been influenced by the overall immediate intervention experience. Finally, although participants’ narratives were highly valuable, this study lacked increased measurement precision of adapted intervention dimensions (e.g., language, method of delivery), which would have allowed for analyses of impact of individual adapted dimensions on specific targeted outcomes. This limitation is also reflective of the type of research design refinements that are needed in the cultural adaptation field (Castro et al., 2010).

Conclusion

Whereas research results are limited to the experiences of parents in this investigation, current findings offer a contribution to the field as first-person narratives of diverse populations exposed to adapted parenting interventions continue to be limited in the cultural adaptation literature. Specifically, parents provided detailed narratives describing the relevance of parenting components in both adapted interventions, including those that were not adopted by participants. Findings also describe the participants’ satisfaction with culture-specific components. Thus, the current investigation provides data highlighting the unique opportunity family therapists have to engage in prevention services aimed at addressing mental health disparities experienced by underserved diverse populations. Continuing to promote applied lines of cultural adaptation research characterized by collaborative approaches and increasingly rigorous research designs, is highly needed to effectively respond to the needs of diverse populations that continue to be overlooked in existing service models.