Systematic Review of Engagement in Culturally Adapted Parent Training for Disruptive Behavior

Abstract

This article reviews the literature reporting engagement (enrollment, attendance, and attrition) in culturally adapted parent training for disruptive behavior among racial/ethnic minority parents of children ages 2–7 years. The review describes the reported rates of engagement in adapted interventions and how engagement is analyzed in studies, methods to develop adaptations, and adaptations that have been implemented. Seven studies were identified. Parental engagement varied across and within studies. Only one study examined whether adaptations improved engagement compared to non-adapted intervention. Frequent methods to develop adaptations were building partnerships or conducting interviews/focus groups with minority parents or community members. Adaptations included addressing cultural beliefs (perceptions of parenting skills), values (interdependence), or experiences (immigration) that affect parenting or receptivity to interventions; ensuring racial/ethnic diversity of interventionists; and addressing cultural relevancy and literacy level of materials. Future research should examine engagement in adapted interventions compared to non-adapted interventions and examine factors (e.g., immigration status) that may moderate impact on engagement.

Disruptive behavior in early childhood consists of noncompliant, delinquent, argumentative, and aggressive behaviors. Disruptive behavior is associated with a number of problems later in life including emotional and behavioral disorders (Belden, Thomson, & Luby, 2008; Ezpeleta et al., 2014; Hong, Tillman, & Luby, 2015), substance abuse (Gunter, Arndt, Riggins-Caspers, Wenman, & Cadoret, 2006), adolescent violence, and adult criminality (Moffitt, 1993; Tremblay et al., 1992). These negative outcomes indicate the importance of effective early treatment and prevention of disruptive behaviors. Parent training interventions are effective for addressing disruptive behavior among young children (Eyberg, Nelson, & Boggs, 2008; Lundahl, Risser, & Lovejoy, 2006). Parent training to address disruptive behavior refers to programs that prepare parents to manage behavioral problems and promote prosocial behavior (Feldman & Kazdin, 1995).

Low Engagement in Parent Training and Disparities in Disruptive Behavior Outcomes

Interventions that include parent training show positive behavior outcomes for racial/ethnic minority¹ families who are retained in interventions (Huey & Polo, 2008). Unfortunately, low engagement in parent training among minority parents is a significant threat to the potential impact for decreasing the significant racial/ethnic disparities in disruptive behavior outcomes. Engagement is most often defined as intervention use, which consists of enrollment, attendance, and retention (McKay & Bannon, 2004). Disparities in outcomes associated with disruptive behavior include higher rates of parental stress, school failure, and juvenile justice involvement among minority children with disruptive behavior (Ezpeleta, Keeler, Erkanli, Costello, & Angold, 2001; Fite, Wynn, & Pardini, 2009; Hinojosa et al., 2012). Literature reviews indicating (a) positive outcomes among minority children with disruptive behavior whose parents demonstrate high intervention attendance (Huey & Polo, 2008; Miranda et al., 2005) and studies demonstrating (b) better outcomes among minority children of parents who are retained in parent training (Begle, Lopez, Cappa, Dumas, & de Arellano, 2012) underscore the importance of identifying potential strategies to maximize enrollment, attendance, and retention.

Cultural Adaptation and Engagement in Parent Training among Minority Parents

Scholars have argued that culturally adapting interventions is one strategy for maximizing engagement among minority families (Bernal, 2006; Bernal, Jiménez-Chafey, & Domenech Rodríguez 2009; Lau, 2006; Parra Cardona et al., 2012). Cultural adaptation is defined as systematic modifications of an intervention to consider language, culture, and context in a way that is compatible with family’s cultural patterns, meanings, and values (Bernal et al., 2009). Scholars have indicated that cultural adaptations of interventions may be beneficial for maximizing engagement when data-based evidence supports a) the need to address a distinct set of risk and resilience factors that contribute to disruptive behavior among a minority group or b) the need to enhance the social validity² of the intervention for minority families (Lau, 2006).

Research Support for Addressing Distinct Risk/Resilience in Adapted Parent Training

Research has indicated that distinct cultural experiences and beliefs play a role in disruptive behavior among some minority groups. Ineffective coping with discrimination among parents is associated with higher disruptive behavior among young African American children (Caughy, O’Campo, & Muntaner, 2004). Stronger parental ethnic identity is associated with fewer disruptive behavior problems among African American, Latino, and Asian parents (Calzada, Brotman, Huang, Bat-Chava, & Kingston, 2009). Further, stronger parental values of independence (a United States American cultural value) among Mexican immigrant mothers are associated with higher disruptive behavior among Mexican American children (Calzada, Huang, Anicama, Fernandez, & Brotman, 2012). These findings suggest that adaptation of parent training to address culturally distinct risk or protective factors of disruptive behavior among minority families may increase engagement by improving parental perceptions of the relevance of intervention content to promote children’s prosocial behavior.

Research Support for Addressing Social Validity in Adapted Parent Training

Problems with social validity may be indirectly indicated when there is lower engagement in non-adapted parent training among minority parents or directly indicated when there is lower acceptability of intervention content among minority parents (Lau, 2006). With regard to indirect evidence of problems with social validity, a number of studies have demonstrated minority parents are less likely than non-minority parents to engage in non-adapted parent training to address early childhood behavior problems or prosocial behavior (Lavigne et al., 2010; Orrell-Valente, Pinderhughes, Valente, & Laird, 1999; Reid, Webster-Stratton, & Beauchaine, 2001). In a study of standard parent training for young children, low income racial/ethnic minority status predicted treatment drop-out 73% of the time; however, low income non-racial/ethnic minority status predicted treatment retention 80% of the time (Lavigne et al., 2010). This finding suggests that lower engagement among minority families may not be entirely due to racial/ethnic differences in socioeconomic status. With regard to more direct evidence of problems with social validity, studies have shown an association between race/ethnicity and the acceptability of parenting strategies that are commonly addressed within the content of parent training interventions. Studies showed that African American parents are more acceptable of spanking than non-racial/ethnic minority parents, and findings indicate this difference is not entirely due to racial differences in socioeconomic status (Regalado, Sareen, Inkelas, Wissow, & Halfon, 2004; Slade & Wissow, 2004; Wissow, 2001). Qualitative data obtained from therapists who delivered parent training to diverse families indicated that intervention modifications were often needed to enhance minority parents’ receptivity to parenting strategies, such as ignoring minor misbehavior (Self-Brown et al., 2011). It is important to further note that racial/ethnic differences in the acceptability of parenting strategies may be due to the influence of cultural beliefs on parenting practices. Cultural beliefs about interdependence among Asian and Hispanic parents (Chao & Kanatsu, 2008), beliefs about racial socialization goals and identity among African American parents (Hill & Tyson, 2008), and the cultural value of respect among Hispanic parents (Calzada et al., 2012) are associated with various parenting practices that are commonly addressed in parent training programs. Overall, the body of literature indicating low engagement in non-adapted parent training interventions and lower acceptability of parenting techniques commonly taught in parenting training programs among minority families signify that cultural adaptation may help increase engagement among minority parents by enhancing parental receptivity to intervention content.

Despite the attention to the potential benefit of culturally adapted interventions to enhance engagement in parent training among minority parents of young children (Bernal, 2006; Bernal et al., 2009; Lau, 2006; Parra Cardona et al., 2012), a paucity of literature summarizes research in this area. The limited literature that has reviewed culturally adapted parent training has focused on the outcomes of interventions (Ortiz & Del Vecchio, 2013). A recent literature review (Ortiz & Del Vecchio, 2013) reported: (a) a number of culturally adapted parent training interventions showed improved outcomes among minority families, and (b) only one study has been designed to compare the outcomes of culturally adapted parent training to non-adapted parent training, with results showing no incremental benefit of culturally adapted parent training on child and family outcomes (McCabe & Yeh, 2009). While researchers have noted that strategies explicitly designed to explore a family’s culture have been implemented as one approach to increase engagement in interventions (Becker et al., 2013; Huey & Polo, 2008), no study has reviewed the literature on parental engagement in culturally adapted parent training. Additional review of the research that describes the reported rates of parental engagement in adapted interventions, summarizes the methods which have been used to develop adaptations, and identifies the cultural adaptations which have been reported in the literature can provide directions for future research examining parental engagement in adapted parent training for young minority children.

Current Review

The purpose of this review is to synthesize the literature on studies reporting minority parents’ engagement in culturally adapted parent training interventions that address disruptive behavior among young children (ages 2–7 years). Specific aims of the review include: (a) to describe rates of parental engagement in adapted interventions and summarize how engagement is analyzed in studies; (b) to summarize methods that have been used to develop cultural adaptations for parent training with minorities; and (c) to identify the cultural adaptations that are reported in the relevant literature.

Method

Search Terms

Searches using the PubMed and PsycINFO databases (years 1970 through March 2014) were conducted. The search consisted of the following key terms or key term combinations: treatment, interventions, prevention, child, preschool age, disruptive behavior, aggression, parent training, parenting, oppositional defiant disorder, conduct problems, and behavior disorder. Searches were conducted using a minimum of two key terms/key term combinations, and all possible combinations of key terms/key term combinations were searched. This initial search of all possible key term combinations yielded 40,162 articles. Articles were selected for further review by one of the study authors if the abstract or study title (if abstract was not available) indicated the study examined an intervention for children’s behavior. The number of articles identified for further review was 338. The search was supplemented by examining the database of studies included in previous parent training reviews and reviews of interventions for disruptive behavior. Therefore, 5 additional articles with abstracts indicating the study examined an intervention for children’s behavior were included.

Selection Criteria

Studies were included in this review if they met the following criteria: (a) the goals of the intervention included impacting disruptive behavior by delivering an intervention for young children (2–7 years) that was explicitly adapted to consider language, culture, socioeconomic status, or social context (e.g., parent education/literacy, poverty, discrimination) for a specific minority group(s); (b) results showed statistically significant positive effect(s) on at least one outcome measure of parenting and/or child disruptive behavior; (c) descriptive information regarding minority parents’ engagement (enrollment, attendance, or attrition) was reported; and (d) quasi-experimental or experimental design. We determined an intervention was explicitly adapted when the authors specified that the intervention was developed or modified for a specific racial/ethnic minority group(s) and described the adaptations. Case studies, single subject design studies, dissertations, studies focused on children with an autism spectrum disorder, studies that adapted an intervention by only translating materials into a different language, and studies conducted outside the U.S. or Puerto Rico were excluded. Publications were screened in two phases to determine if eligibility criteria were met. In the first phase, (a) the abstract and/or methods sections of the articles were screened to determine if the child age range criterion was met, (b) the methods and results sections of the articles were reviewed to determine if engagement (enrollment, attendance, or attrition) was reported, and (c) the results section was reviewed to determine statistically significant improvement on at least one outcome measure. In the second phase, articles were examined to determine if the intervention was explicitly adapted to consider language, culture, or socioeconomic/social context.

Data Collection Process

The study authors developed a data extraction document, pilot tested it on two included studies, and refined it accordingly. The following data elements were extracted from the included studies: sample demographic characteristics, recruitment and retention strategies, sample size, descriptive information about the interventionists, descriptive data on engagement, descriptions of methods that were used to culturally adapt interventions, descriptions of the cultural adaptations that were implemented, and whether the study involved statistical analysis to determine if cultural adaptation improved engagement. All articles were reviewed independently by the two study authors, and any disagreements (6% of articles) were resolved by further discussion and review.

Results

Our initial search yielded 343 articles. Seven studies met inclusion criteria (Figure 1). Table 1 indicates characteristics of the 7 reviewed studies that met inclusion criteria. For each study, we calculated engagement based on the availability of data reported. Engagement was categorized as enrollment, attendance, and dropout/attrition. Enrollment was calculated as the percentage of parents who enrolled in the intervention after meeting eligibility criteria or after being informed of the opportunity to participate in the intervention. Attendance was calculated as the percentage of the average number of sessions attended. Finally, attrition was calculated as the percentage of parents who dropped out of the intervention.

Figure 1.

Flow of study selection

Table 1.

Characteristics of Reviewed Studies and Parent Enrollment, Attendance, and Dropout

Study Authors/ (Adapted PT)	Sample Type	Study Exclusion Criteria	Race/ Ethnicity of Study Samplea	Family Income	Parent Edu- cation	Child Sex (%Male)	Child Age	N	Interven- tionistb	% Enroll- Mentc	% Average Number of Attended Sessions	% Drop- out
Baker et al 2011/(Incredible Years)	Families recruited from child care centers	None	25% AA 31% HA 30% NHW 14% mixed/other	All AAs and HAs from centers where median income was $28,250	Not Reported	52%	Mean = 4.6 years	51	Clinical Psychology Doctoral Students	41% AA 30% HA 78%NHW	53% AA 73% HA 64% NHW	N/A
Brotman et al 2011/(Parent Corps)	Families of children enrolled in Pre-K program	Non-English speaking	39% AA 24% HA 12% AS 12% mixed 13% NHW	53% below 150% Federal Poverty Level	44% ≥ high school diploma	44%	Mean = 4.1 years	118	Psychologist, Social Workers, Teachers, Educational Assistants, and Family Workers	42% All racial/ethnic groups d	46% All racial/ethn-ic groups d	N/A
Coard et al 2005/(Culturally Modified Helping the Non-compliant Child)	AA Families recruited from the community	Child mental health, medical, or neurological condition; bi-racial caregivers and children	100% AA	50% received public assistance	Not reported	60%	5–6 years	16	Trained group leaders	84% AA	85% AA	N/A
Gross et al 2009/(Chicago Parenting Program)	Children in childcare serving low-income families	Non-English Speaking	59% AA 32% H 9% other	Not Reported	81% ≥ high school diploma	56%	2–4 years	156	Trained group leaders	N/A	36% All racial/ethn-ic groups d	N/A
Matos et al 2009/(Culturally Modified Parent-Child Interaction Therapy)	HA Children with IQ ≥ 80, ADHD and all except one with oppositional defiant disorder	Child developmenttal disability; parental domestic violence, major depression, substance abuse, or mental retardation	100% HA	Not Reported	Not Reported	Not Reported	4–6 years	20	Graduate Students	N/A	N/A	5% HA
McCabe et al 2009/(Culturally Modified Parent-Child Interaction Therapy)	HA Children with Disruptive Behavior	Participation in another intervention for child disruptive behavior	100% HA	67% ≥ high school diploma	Not Reported	70%	4–6 years	21	Graduate Students	82% HA	N/A
O’Connor et al 2012/(INSIGH-TS)	Family of children enrolled at schools	None	54% AA 44% HA 2% other	Not Reported	Not Reported	56%	M = 6.07 (SD = 1.01)	202	Facilitators	Not Reported	70% All racial/ethnic groups d

Note: AA= African American, HA = Hispanic, NHW = Non-Hispanic White.

^aPercentages reflect the racial/ethnic makeup of the entire sample completing enrollment.

^bInformation in this column is the title used in the article to describe the interventionists.

^cPercentage is the proportion parents who enrolled in the intervention after meeting eligibility criteria or after being informed of the opportunity to participate in the intervention.

^dPercentage includes minority and non-Hispanic White families.

Rates of Engagement in Culturally Adapted Parent Training

Table 1 shows that the percentages of parental engagement (enrollment, average number of attended sessions, and dropout) varied across studies. Enrollment, defined as the percentage of parents who were eligible and invited to participate in the intervention, was reported in 4 studies. Rates of enrollment ranged from 30% to 84%. We were able to calculate in 5 studies the percentage of the average number of sessions attended. The percentages ranged from 36% to 85%. Finally, drop-out was reported in 2 studies. One study had 5% attrition, and the second study had 43% attrition. Importantly, while 4 of the 7 studies included only parents from minority backgrounds, 3 of the 7 studies included non-minority and minority parents (Table 1). In these 3 studies, the percentages of engagement were reported for the total sample of non-minority and minority parents.

Analysis of Engagement in Culturally Adapted Parent Training

Only one study was designed to statistically examine whether culturally adapted parent training improved engagement among minority parents. Using a randomized controlled trial, McCabe and Yeh (2009) found that culturally adapted parent training compared to non-adapted parent training did not show significant differences in dropout among Mexican American families.

Methods for Developing Cultural Adaptations

Reported methods for developing cultural adaptations in each study are reported in Table 2 and described below.

Table 2.

Surface and Deep Structure Cultural Considerations in Parent Training with Young Racial/Ethnic Minority Children

Study Authors	Strategies to Develop Cultural Adaptations	Surface Structure Considerations1	Deep Structure Considerations2	Engagement	Recruitment/Retention Strategies
		African American-only Sample
Coard et al (2004)	Used literature documenting racial socialization as a culturally-distinct protective factor of disruptive behavior Focus groups with AA parents	Matched race/ethnicity of group leaders to parents [constituent-involving] Used African American common language expression, such as use of the term “we” [sociocultural] Intervention delivered in setting designed for African Americans (i.e., decorations that represent African Americans) [sociocultural]	Taught parental racial socialization practices [sociocultural; evidential] Emphasized values associated with AA background (i.e., collective responsibility) [sociocultural] Used African proverbs, sayings and affirmations, poems, quotes, symbols, and pledges [sociocultural] Used prayer [sociocultural]	84% Enrollment 85%Attendance	Recruitment included informal presentations by research staff at local community agencies Recruitment materials emphasized strengths and culturally-based philosophy Research staff were AA Pictures of program staff and biographical narratives on all written recruitment materials Research assessments completed in family’s home $30 reimbursement for research assessments Meals/childcare provided
		Hispanic-only Sample
Matos et al (2006)	Interviews with Puerto Rican parents and therapists Used observations from pilot study Used framework of cultural sensitivity (Bernal et al., 2005)	Translated materials into Spanish [linguistic] Simplified parent materials [linguistic] Provided examples in parent materials that appear relevant to the daily life of Puerto Ricans (for example, manual examples that included objects such as chimney/snowman were replaced) [peripheral]	Implemented different discipline strategy (loss of privileges) than outlined in non-adapted intervention (time-out) [sociocultural] Discussed extended family involvement in treatment and parenting [sociocultural] Implemented psycho- educational module to address expectations (topics included risk/protective factors, etiologies of behavior problems) Extended session duration; changed termination criteria	5% Dropout	Recruitment included newspaper, TV, and radio advertisements, and preschool/clinic referrals $15– $40 research assessments incentives
		Hispanic-only Sample
McCabe et al (2005)	Focus groups with Mexican American parents and therapists Literature search for traditional values, practical treatment barriers, and cultural barriers Consultation from Mexican American therapists, cultural adaptation experts, and the intervention developer	Translated materials into Spanish [linguistic] Simplified parent materials [linguistic] Spanish speaking interventionists	Renamed intervention and used another word for “therapist” to address stigma [sociocultural] Used engagement protocol to address treatment expectations/extended family involvement [sociocultural] Assessed culturally influenced beliefs that may affect intervention response [sociocultural] Elicited parental complaints due to value of respect for authority [sociocultural] Attended to rapport building due to the value of personalismo [sociocultural]	82% Enrollment 43% Dropout	Recruitment by phone $100 research assessment incentives
		Diverse Racial/Ethnic Minority Sample
Baker et al (2011)	Not reported	Spanish language materials [linguistic] Bilingual intervention leaders	“Cultural differences” in parenting discussed during program [sociocultural]	41% AA Enrollment 30% HA Enrollment 53% AA Attendance 70% HA Attendance	Recruitment included mailings; $30 recruitment meeting incentives Sessions provided in evening Meals/childcare provided Contacted after missed sessions
Brotman et al (2011)	Established Community Advisory Board	Racial/ethnic minority intervention leaders [constituent-involving] Delivered in school setting	“Cultural values” related to parenting discussed during program (e.g., values related to obedience and respect for elders) [sociocultural]	72% Enrollment 46% Attendance	Recruitment presentations by study staff Research measures completed in home/school Intervention conducted at school Meals/childcare provided Activities provided for older children in family Focused on relationship and motivation building
		Diverse Racial/Ethnic Minority Sample
Gross et al (2007)	Established a Parent Advisory Council	Used videotape vignettes of racially/ethnically diverse families from the racial/ethnic minority group(s) [peripheral] Matched race/ethnicity of group leaders to parents [constituent-involving] Intervention delivered in community child care setting	Provided teaching rationales, videotaped vignettes, and handouts to address negative perceptions of parenting strategies [sociocultural] Addressed stressors of immigration, maintaining traditions, and racism [sociocultural]	36% Attendance	Recruited from childcare centers Meals/childcare provided Provided $30 incentives for research assessment
O’Connor et al (2012)	Cultural/Content Experts Used observations from pilot study Community partnership	Addressed the cultural relevance of intervention materials [peripheral]	Invited additional parental figures (e.g. extended family) to participate [sociocultural]	70% Attendance	Provided $30 incentives for research assessment Provided up to $170 for intervention attendance

Notes. AA = African American, HA = Hispanic. Peripheral strategies are modifications to the observable properties of interventions. Linguistic strategies alter language used in materials to make them comprehensible. Constituent involving strategies utilize the cultural knowledge and experiences of members of the minority group. Sociocultural strategies recognize, reinforce, or build upon cultural values, beliefs, and behaviors. Evidential strategies use “evidence” for a specific group or experiences from individuals with similar backgrounds to increase perceived relevance of information.

¹Defined as matching intervention materials and messages to observable patient characteristics

²Defined as incorporating the cultural, social, historical, environment, or psychological aspects

Identification of culturally distinct protective factors of disruptive behavior

One study based cultural on literature documenting a culturally-related protective factor of disruptive behavior [e.g., effective parental coping with discrimination (Caughy et al., 2004)]. Coard, Wallace, Stevenson, and Brotman (2004) anchored their modifications in empirical research demonstrating the relationship between racial socialization parenting practices and positive outcomes for African American families. Racial socialization is defined as the processes by which children acquire the behaviors, perceptions, values, and attitudes of a racial group and develop the perception of seeing themselves and others as members of the group (Coard et al., 2004).

Identification of Cultural factors that may impact intervention delivery

One study referenced literature identifying cultural values, experiences, and beliefs that are important for intervention delivery among Mexican American parents. McCabe et al. (2005) identified traditional values of familism, personalismo, collectivism, relationship hierarchy/authority, and adherence to traditional gender roles. Familism is a value placed on the importance of relationships with family relative to friends or co-workers, particularly in matters of childrearing and child discipline (Zuniga, 1997). Personalismo is a value placed on warm interpersonal relationships over individual achievements (Martinez & Eddy, 2005). The value of collectivism emphasizes affiliation and cooperation, and avoidance of confrontation and competition (Kashima et al., 1995). Traditional gender roles in Mexican American families include maternal responsibility for childrearing and paternal responsibility for providing financial support (Koss-Chionino & Vargas, 1999). McCabe et al. (2005) also indicated that literature documenting practical barriers (i.e., financial constraints and transportation) and culturally-related barriers (i.e., cultural differences between staff and the family, immediate and extended family support for treatment, acculturation, treatment attitudes/expectations, and beliefs about causes of child behavior difficulties) informed cultural adaptations for Mexican American families.

Focus groups and interviews

Three of the parent training studies reported that qualitative data were obtained from minority parents of children with disruptive behavior, therapists, and/or community members. Two studies obtained qualitative data to determine and inform strategies for enhancing the acceptability and viability of the intervention. Specifically, McCabe et al. (2005) conducted focus groups and interviews with Mexican American mothers and fathers of youth with behavior disorders and Mexican American therapists. Focus groups and interviews involved describing a non-adapted parent training program to parents and therapists and asking them to indicate aspects of the program that were “appealing or unappealing”, as well as suggestions for intervention improvement. Similarly, Matos et al. (2006) conducted individual interviews with Puerto Rican parents and therapists who completed or delivered a preliminary culturally adapted parent training intervention. They were asked to evaluate the parenting skills and rationales provided, as well as the intervention format, procedures, materials, and duration. They were also asked to identify “cultural, personal or spiritual values” or barriers that may affect program efficacy and to provide suggestions for program improvement. Coard, Wallace, Stevenson, & Brotman (2004) conducted focus groups with low-income African American parents to identify the prevalence, content, and techniques for implementing parent racial socialization practices to inform their parent training adaptations for African American families.

Community advisory board participation

Three studies gained participation from community members in the form of community advisory boards to enhance the acceptability and viability of the intervention. Gross et al. (2007) convened a Parent Advisory Council of African American and Latino parents from a range of socioeconomic backgrounds to develop and provide feedback on strategies for delivering the parent training program in a “culturally and contextually relevant” manner. The council advised intervention developers on the depictions for videotape vignettes and how to introduce parenting strategies in a “culturally congruent manner” for African American and Latino parents. O’Connor et al. (2012) partnered with and conducted focus groups with community members (parents, community leaders, teachers) to discuss the intervention content and “cultural implications” of the intervention (McClowry & Galehouse, 2002). Finally, Brotman et al. (2011) established a Community Advisory Board who helped to identify paraprofessional intervention staff and to ensure the program was “consistent with the values and priorities of the target community.” The board also provided feedback on how to deliver the intervention.

Expert consultation, pilot investigation, and application of a cultural framework

Other strategies to develop adaptations included obtaining feedback from experts in two studies. Cultural and content experts were involved in the development of parent training in the study by O’Connor et al., 2012. In the study by McCabe et al. (2005), experts (i.e., researchers focused on cultural adaptation, Mexican American therapists, and the developer of the non-adapted version of parent training) finalized adaptations. Adaptations were also based on observations from pilot investigations in 3 studies (Brotman et al., 2011; Matos, Torres, Santiago, Jurado, & Rodriguez, 2006; O’Connor, Rodriguez, Cappella, Morris, & McClowry, 2012) and an existing framework of cultural sensitivity of interventions in one study (Matos et al., 2006).

Types of Cultural Adaptations Implemented in Studies

The types of cultural adaptations that were implemented in the reviewed studies, as well as each study’s general recruitment and retention strategies are reported in Table 2. The types of cultural considerations are divided into two categories and are defined according to two dimensions: surface structure and deep structure. The two study authors categorized the cultural considerations independently, and any disagreements were resolved by further discussion and review. Surface structure cultural considerations, which have also been titled presentation strategies, can be defined as matching intervention materials and messages to observable characteristics of the population, such as using people, language, or locations familiar to and preferred by the target families. Deep structure cultural considerations, which have also been titled content strategies, can be defined as incorporating the cultural, social, historical, environmental, or psychological aspects that may influence the target behavior, such as parenting practices or child behavior (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999). Based on findings from a recent literature review to identify common elements in cultural adaptations (Barrera, Castro, Strycker, & Toobert, 2013), we further divided the cultural considerations into the organizational scheme posed by Kreuter, Lukwago, Bucholtz, Clark, and Sanders-Thompson (2003). This scheme contains the following categories: (a) peripheral strategies that modify the observable properties of intervention materials, (b) linguistic strategies that alter language used in intervention materials to make them comprehensible, (c) constituent-involving strategies that utilize the cultural knowledge and experience of members of the minority group, (d) sociocultural strategies in which a minority group(s) cultural values, beliefs, and behaviors are recognized, reinforced, and built upon, and (e) evidential strategies that use “evidence” for a specific group or experiences from individuals with similar backgrounds to increase the perceived relevance of information (Kreuter et al., 2003).

Strategies to address cultural beliefs, values, and experiences related to parenting or receptivity to interventions

Of note in the reviewed studies are attempts to address parent cultural beliefs, values, and experiences that relate to parenting among minorities. McCabe et al. (2005) reported implementing an intake questionnaire to assess Mexican American values and beliefs about various parenting strategies and styles (e.g., Do parents feel comfortable praising their children?). A computerized report based on questionnaire responses was developed for each family and used by therapists to tailor topics of discussion for each family. Furthermore, to address the cultural value of personalismo, interventionists spent extra time during each session to focus on rapport building with families. The values of collectivism and familism were addressed by having the interventionists conduct home visits and contact mothers, fathers, and grandparents. During telephone calls and home visits, interventionists’ goals included assessing familial support for the intervention and creating an engagement plan for other family members who are involved in decision-making and parenting. Engagement of fathers and grandparents is a focus throughout the intervention, and plans are developed with the participating caregiver if there are other family members who discourage intervention participation. For example, non-participating family members may be contacted by the interventionist or provided with written intervention materials. To address the value of relationship hierarchy/authority, interventionists discussed parental concerns about the program and encouraged parents to voice any complaints during each session. Coard et al. (2004) taught parenting strategies to promote racial socialization parenting practices, which included: (a) discussing and problem-solving children’s experiences of social exclusion from peers due to their race, (b) teaching skills for advocating for children to overcome poor relationships with and low expectations from school staff, (c) providing education about the developmental progression of racial awareness and identity among children, (d) teaching skills for discussing with children, race-related information in a developmentally- appropriate manner, and (e) supporting parents in accessing culturally affirming community resources. Similarly, Gross et al. (2009) emphasized discussion of stress related to being immigrants or concerns about maintaining cultural traditions among Hispanic parents and discussion of stress related to racism among African American parents. Gross et al. (2007) developed a list of effective discipline principles that were rated as acceptable among African American and Hispanic community members, and the principles were disseminated. To address acceptability of parenting strategies, Matos et al. (2006) reported teaching some parents to use loss of privileges as a discipline technique because it was more acceptable than time-out among some Puerto Rican families and therapists. Brotman et al. (2011) and Baker et al. (2011) reported that cultural differences in parenting and cultural values (e.g., value of child obedience and respect for elders) were discussed with parents during the program.

Ensuring literacy level and culturally relevant content of intervention materials

Several studies reported explicit modifications to intervention materials. Modifications included providing parent handouts in Spanish for Hispanic families (Baker, Arnold, & Meagher, 2011; Matos et al., 2006; McCabe, 2005), ensuring that parent handouts included simplified language (Matos et al., 2006; McCabe, 2005), and confirming the materials were culturally relevant (Gross, 2007; Matos et al., 2006; O’Connor et al., 2012).

Addressing the language and race/ethnicity of interventionists and considering the intervention setting

Six of the seven studies reported explicit attention to the race/ethnicity, language proficiency, and/or language expression of the interventionists. This included utilizing bilingual therapists for parent training with Hispanic parents (Baker et al., 2011; McCabe, 2005) and matching the race/ethnicity of the interventionist to the families participating in the intervention (Brotman et al., 2011; Coard et al., 2004; Gross, 2007). Coard et al. (2004) also reported interventionists used common African American language expression, as well as African proverbs, sayings and affirmations, poems, quotes, symbols, and pledges. Finally, several studies reported attention to delivering the intervention in particular settings. Gross et al (2007) reported delivering in the intervention in child care settings and Coard et al (2004) reported intervention delivery in a setting with motif that are representative of African Americans.

Discussion

The purpose of this review was to synthesize the literature on studies reporting U.S. racial/ethnic minority parents’ engagement in culturally adapted parent training interventions that address disruptive behavior among young children ages 2–7 years. Our review of the literature indicates that few studies have reported engagement in culturally adapted parent training among racial/ethnic minority parents. Further, the proportion of parents who enrolled, attended sessions, or dropped out of the intervention varied within and across studies. Only one study was designed to examine whether an adapted intervention improved engagement compared to a non-adapted intervention. Thus, the current state of the literature does not allow determination of whether adapted parent training improves engagement among minority families. However, it is important to note that some of the culturally adapted interventions described relatively high enrollment and/or attendance compared to studies of non-adapted parent training with diverse samples that have reported rates of 45–60% enrollment (August, Lee, Bloomquist, Realmuto, & Hektner, 2003; Begle et al., 2012; Brotman et al., 2005) and 45–55% average attendance (Begle et al., 2012; Linares, Montalto, Li, & Oza, 2006). Such findings point to the need for studies that compare culturally adapted interventions to non-adapted interventions to determine whether culturally adapted interventions are beneficial for increasing engagement among minority parents.

Recommendations for Future Research

We provide several recommendations for future research on parental engagement in culturally adapted parent training. First, findings from this review suggest that conducting interviews or focus groups, or establishing community advisory boards with parents and community members are feasible strategies for developing cultural adaptations to parent training interventions that could be examined in future studies. The development of community advisory boards aligns with an increasing focus on using a Community Based Participatory Research (CBPR) approach. CBPR emphasizes partnerships between communities and researchers for the purpose of developing effective interventions that are culturally and contextually relevant and address disparities among racial/ethnic minority families (Viswanathan M, 2004; Wallerstein & Duran, 2010; Wallerstein & Duran, 2006).

Second, this review focused on enrollment, attendance, and drop out as measures of engagement given these are most commonly examined (Becker et al., 2013). However, diverse measures of engagement should be used in future studies to determine the impact of adapted interventions across different measures. Additional measures should include parental adherence to intervention procedures and level of parental involvement during intervention sessions. Parental attitudes/cognitions that are associated with attendance and adherence should also be examined, such as motivation to participate in interventions and change parental behaviors, or the degree of receptivity to intervention content and procedures.

Third, it is important to note that most of the studies in this review were conducted with parents with relatively low educational attainment and family incomes. It will be important in future studies to recruit minority families from diverse socioeconomic backgrounds to determine whether sociodemographic characteristics (i.e., family income, parental educational background, parental literacy, and parents’ primary language) moderate the impact of culturally adapted parent training on engagement. Similarly, cultural factors that should be examined as moderators of culturally adapted parent training in future research are level of parental acculturation, level of parental racial/ethnic identity, as well as level of immigration, acculturation, or discrimination-related stress. Cultural values, such as familism, personalismo, respecto, and degree of importance placed on children’s racial socialization may also moderate the impact of culturally adapted interventions. Finally, parental acceptance of various parenting skills (e.g., time-out, corporal punishment) may moderate intervention effects and should be assessed in future studies.

Implications for Implementation of Parent Training with Minority Parents

Information from the current review can be used to inform quality improvement of parent training with minority families. Our findings related to the use of parental interviews and focus groups to develop adaptations fit with the increasing emphasis on involving families in quality improvement efforts in child intervention programs (Blau, Huang, & Mallery, 2010). For example, interviews or focus groups can be conducted to determine parental perceptions of barriers to engagement and potential strategies for intervention improvement.

Finally, while researchers have called for the need to consider language, culture, and context in parent training, to our knowledge, no systematic review has summarized cultural adaptations that have been implemented with minority families. This review describes several strategies that can be considered for implementation among interventionists who wish to address language, culture, and context within parent training programs delivered to African American or Hispanic parents. The strategies include: assessment and discussion of parenting values and beliefs, promoting effective strategies for managing experiences related to discrimination or immigration; ensuring the availability of racially/ethnically diverse intervention providers; providing the intervention in the family’s primary language; ensuring the cultural relevancy and appropriate literacy level of intervention materials; providing the intervention in a community location that is acceptable and accessible for parents; and providing an intervention title that minimizes stigma. Importantly, due to the small number of studies in this review, we did not describe the types of cultural adaptations that have been implemented separately for different minority groups. Types of cultural adaptations may be more relevant for some racial/ethnic minority groups compared to others.

Limitations

There are several limitations of this review that are important to note. The small number of studies that were available for review limits the generalizability of our findings to the larger population of young racial/ethnic minority children. In particular, no study reported the inclusion of Asian Americans or Native Americans in their sample, thus restricting information about cultural adaptations that have been implemented among these two groups.

Conclusions

Despite the limitations, this systematic literature review reveals several methods that can be used to develop cultural adaptations for parent training and describes concrete strategies that have been implemented to address culture, language, and context in parent training for racial/ethnic minority families. It is hoped that the recommendations for future research on culturally adapted parent training encourage attention to adequate testing of parent engagement given the importance of engagement to achieve an impact on disparities in outcomes associated with disruptive behavior among minority children.