Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2018 Sep 1.
Published in final edited form as: J Lat Psychol. 2017 Jul 13;5(4):261–274. doi: 10.1037/lat0000095

Parental acculturation level moderates outcome in peer-involved and parent-involved CBT for anxiety disorders in Latino youth

Daniella Vaclavik 1, Victor Buitron 2, Yasmin Rey 3, Carla E Marin 4, Wendy K Silverman 5, Jeremy W Pettit 6
PMCID: PMC5720156  NIHMSID: NIHMS884856  PMID: 29226037

Abstract

Cognitive behavioral therapies (CBTs) are efficacious treatments for anxiety disorders in Latino youth. However, there is a gap in knowledge about moderators of CBT outcomes in Latino youth. This study addresses this gap by examining parental acculturation as a moderator of youth anxiety outcomes in a randomized controlled trial of parent-involved CBT (CBT/P) and peer-involved group CBT (GCBT) in 139 Latino youth (ages 6 to 16 years; mean age = 9.68 years). Comparable youth anxiety reduction effects were found for CBT/P and GCBT. Parental acculturation to majority US culture, but not identification with country of origin, significantly moderated youth anxiety outcomes: at low levels of parental acculturation to majority US culture, youth posttreatment anxiety scores were lower in GCBT than CBT/P; at high levels of parental acculturation to majority US culture, youth posttreatment anxiety scores were lower in CBT/P than GCBT. These findings provide further evidence for the efficacy of CBTs for anxiety disorders in Latino youth and also provide guidance for moving toward personalization of CBTs’ selection depending on parental acculturation levels.

Keywords: anxiety disorders, children and adolescents, parents, peers, cognitive behavior therapy, acculturation, Latino

Anxiety disorders are common and cause considerable distress and impairment in Latino children and adolescents (hereon referred to as youth). The lifetime prevalence rate of any anxiety disorder in Latino adolescents exceeds 30% (National Comorbidity Survey - Adolescents, 2005). Cognitive behavioral therapies (CBTs) are efficacious treatments for anxiety disorders in Latino youth (Pina, Silverman, Fuentes, Kurtines, & Weems, 2003). However, there is a gap in knowledge about moderators of CBT outcomes in Latino youth. This gap is unfortunate given the high prevalence of anxiety disorders and given that, despite CBTs’ efficacy, up to 25% of Latino youth with anxiety disorders do not respond well to CBT (Pina et al, 2003), a rate generally comparable to the mainstream population (Silverman, Pina, & Viswesvaran, 2008). Identification of moderators of CBT outcomes in Latino youth would provide insight into “which CBT works best for whom” and help guide the development of personalized treatment strategies that might produce superior treatment outcomes (Compton et al., 2014).

This study is a step towards addressing this gap by its examination of parental acculturation as a moderator of Latino youth anxiety outcomes in a randomized controlled trial (RCT) of parent-involved CBT (CBT/P) and peer-involved group CBT (GCBT). Informed by research documenting significant associations between youth anxiety and parenting variables such as high psychological control (e.g.,Varela et al., 2013) and peer relationship variables such as low social skills (e.g., Motoca, Williams, & Silverman, 2012), researchers adapted individual youth CBT protocols to target parenting variables (CBT/P) or peer variables (GCBT) with an eye toward enhancing anxiety reduction effects (e.g., Silverman, Kurtines, Jaccard, & Pina, 2009). Although little evidence to support enhancing effects has emerged (e.g., Silverman et al., 2008), it is possible that enhancing effects may be found in subsets of youth who display certain personal, cultural or familial characteristics, such as parental acculturation levels in Latino families. That is, it is possible that youths’ responses to CBT/P versus GCBT are moderated by characteristics of youth or their families. In the following sections, we briefly describe CBT/P and GCBT and then discuss parental acculturation levels in Latino families as a potential moderator of response to these CBTs.

CBT/P and GCBT

Parent involved CBTs, or CBT/Ps, include standard components of CBTs for youth anxiety such as psychoeducation, cognitive restructuring, and exposure, and target parent variables such as parental psychological control or negative parent-youth relationships (Thulin et al, 2014). Peer involved CBTs delivered in a group format, or GCBTs, also include standard components of CBTs for youth anxiety and further target specific peer variables such as youth social skills or peer-youth relationship quality (Beidel, Turner, & Morris, 2000). In the present article, we report on a subset of participants, all Latino, who participated in an RCT of a CBT/P targeting parental psychological control and negative parent-youth relationships and a GCBT targeting youth social skills and positive peer-youth relationships (Silverman et al., 2017). Parent variables were targeted in CBT/P by explicitly focusing on desirable parenting behaviors and parent-youth interactions through didactic instruction, modeling, and role-plays with parent-youth dyads in session. Peer variables were targeted in GCBT by explicitly focusing on desirable social behaviors and peer interactions through didactic instruction, modeling, and role-plays in groups of 6 to 10 youths. For additional details on the treatment conditions and study design, we refer readers to Silverman et al. (2017).

Parental Acculturation and Parenting

Parent-youth interactions and youth peer relationships do not occur in a vacuum, but in ecological and cultural contexts. Among Latinos in the United States (US), these contexts are fluid and represent an evolving balance of ethnic minority cultural values and majority or “mainstream” cultural values. This evolution, including the process of adapting to and identifying with majority culture, is known as acculturation (Ryder Alden, & Paulhus, 2000). Acculturation is a complex and multidimensional process by which an individual gradually begins to adapt and identify with a host culture (Ryder et al, 2000), with levels of acculturation to the dominant culture being independent from the identification with the original culture (i.e., enculturation).

The process of acculturation can be stressful. Stress related to the process of acculturation may occur on contextual/environmental levels and include variables such as societal discrimination, on the family level and include variables such as parent-child conflict about customs and values, and on the individual level and include variables such as coping strategies for balancing discrepant or even contradictory customs and values (Lawton & Gerdes, 2014). Latinos in the United States face multiple and varied challenges, such as acculturative stress and marginalization (Capielo, Delgado-Romero, & Stewart, 2015), intergenerational conflicts, discrimination, and challenges due to disparities in income and access to healthcare (U.S. Department of Health and Human Services, 2001). These challenges can have a deleterious influence on levels of stress and well-being of parents and families, and also may influence parenting behaviors and the parent-child relationship (e.g., overprotection, parental psychological control, parent-child conflict; Lawton & Gerdes, 2014). Theory and research have drawn connections between parental acculturation, parental psychological control, and youth anxiety.

Learning models of anxiety consider the parenting and the parent-child relationship important contributors to development and maintenance of youth anxiety (Gerull & Rapee, 2002). Certain parenting behaviors are associated with a decreased sense of control and higher levels of anxiety in youth, such as parental psychological control (Wood, McLeod, Sigman, Hwang, & Chu, 2003). Parental psychological control refers to behaviors performed to induce child compliance and inhibit youths’ psychological autonomy through psychological tension, including emotional invalidation and manipulation (Barber, 1996). Psychological control differs from behavioral control, which refers to behaviors performed to control youths’ actions, including supervision and enforcement of rules (Barber, 1996). Whereas psychological control is significantly and positively associated with anxiety in youth, behavioral control is significantly and negatively associated with externalizing problems in youth (e.g., disruptive behaviors, drug use; McLeod, Wood, & Weisz, 2007). Nevertheless, some forms of parental control can have protective functions in Latino families whereas other forms of parental control can enhance risk (Domenech-Rodriguez et al., 2009).

Parenting behaviors, including parental psychological control, are influenced by cultural norms, values, and belief systems (Lawton & Gerdes, 2014; Varela & Hensley-Maloney, 2009). For example, some studies have found that Latino parents tend to be more controlling and authoritarian and less autonomy granting (Varela et al., 2004) compared with non-Latino parents, however, Latino parents’ interactions with their children have also been characterized as high in warmth and acceptance (Varela et al., 2013). Researchers have suggested these parenting practices might stem from Latino cultural values such as respeto (Halgunseth, Ispa, & Rudy, 2006). Respeto refers to the hierarchical respect for authority, which demands obedience (Guilamo-Ramos, Dittus, Jaccard, Johansson, & Acosta, 2007).

Parental acculturation levels are significantly associated with parenting behaviors, including parenting behaviors relevant to youth anxiety. In Latino samples, some studies have found that low parental acculturation is significantly associated with high levels of parental psychological control and decreased autonomy granting (Smokowski et al., 2009, 2014), and these parenting behaviors are significantly associated with levels of youth anxiety (Varela et al., 2013). Other studies have found a more complex association between parental control and youth anxiety in Latinos (see Varela & Hensley-Maloney, 2009 for a review). For example, Varela, Sanchez-Sosa, Biggs, and Luis (2009) found that maternal control was significantly and positively associated with youth anxiety, but paternal control was negatively associated with youth anxiety in Latinos. Luis, Varela, and Moore (2008) found that parental control was significantly associated with youth anxiety in Mexicans, but not in Mexican-Americans. These findings highlight the complexity of the associations between parental control and youth anxiety across contexts and parental characteristics, including levels of parental acculturation.

Given the complexity of these associations, it was of interest to examine the potential influence of parental acculturation levels on youth response to CBT/Ps that explicitly target parenting variables such as parental psychological control. On the one hand, CBT/Ps that directly involve parents in treatment and specifically target parenting behaviors may be congruent with the customs and values of Latino families, especially those low in acculturation who desire to be involved in the treatment process (Calzada et al., 2013). For example, parental involvement in a treatment for youth PTSD was associated with superior treatment outcomes in Latino youth (Santiago et al., 2014).

On the other hand, if CBT/Ps target specific parenting behaviors in ways that are incongruent with the customs and values of Latino parents low in acculturation, the result may be poorer treatment outcome. This could be the case especially for CBT/Ps that target parental psychological control, to the extent that intervening to reduce parental psychological control may at times seem to conflict with values of respeto. In Latino families low in acculturation, CBTs that target other variables, such as peer relationship variables in GCBT or other parenting behaviors in CBT/Ps (e.g., parental warmth and acceptance), might be more congruent with family values and lead to superior youth anxiety outcomes. The importance of selecting treatment approaches that align with families’cultural values has been highlighted by others (e.g., the Cultural Match Theory; La Roche, Batista, & D’Angelo, 2014), because a strong alignment, or match, is expected to enhance both use of treatment services and treatment outcomes.

The literature on acculturation as a moderator of treatment outcomes in Latino families is mixed and has focused on a wide range of non-anxiety problem behaviors (e.g., substance use, trauma, child externalizing disorders) (for a review see Stein & Guzman, 2015). There is some evidence that parental acculturation may influence youth treatment outcomes in Latino families, but the nature of the influence and the circumstances in which influence occurs need empirical investigation (Stein & Guzman, 2015). The literature on acculturation and treatment outcomes for youth anxiety is small and evidence of an association between acculturation and treatment response is mixed. Although several studies have investigated CBT treatment outcomes in mixed ethnicity samples of Latinos and non-Latinos (e.g., Pina et al., 2003; Silverman et al., 2009), these studies have focused primarily on differences between Latinos and White European-Americans without considering acculturation. Another study in a mixed ethnicity sample failed to find support for ethnicity or language status (a proxy for acculturation) as a moderator of outcome in a child anxiety prevention program (Pina, Zerr, Villalta, & Gonzales, 2012). Similarly, initial efforts to develop and evaluate culturally adapted interventions have not resulted in enhanced youth anxiety reduction outcomes (Pina, Little, Knight, & Silverman, 2009). However, to our knowledge no study has examined parental acculturation as a moderator of youth anxiety CBT outcomes in Latinos.

Present Study

The present study examined two aspects of parental acculturation levels, acculturation to majority US culture and identification with country of origin culture, as moderators of youth anxiety outcomes in CBT/P versus GCBT in a Latino sample. The primary research question was whether youth anxiety outcomes in CBT/P versus GCBT would significantly differ as a function of parental acculturation levels to majority US culture. Given the evidence reviewed above documenting relationships between parental acculturation, parenting variables, and youth anxiety, we hypothesized parental acculturation levels to majority US culture would significantly moderate youth treatment outcome, such that youth anxiety levels at posttreatment would be lower in GCBT compared to CBT/P when parental acculturation levels were low. That is, in families who endorsed low acculturation to majority US culture, we expected youth would display superior outcomes following a treatment that targeted peer relationship variables in a group setting (GCBT) compared with a treatment that targeted parenting variables such as parental psychological control (CBT/P). At the same time, we recognized the possibility that directly involving parents and targeting parenting variables in the treatment process (CBT/P) could be consistent with the values of families who endorsed low acculturation and thus may lead to enhanced outcomes compared with a treatment that did not directly target parenting variables (GCBT). We expected acculturation to majority US culture, but not necessarily identification with country of origin culture (enculturation), to significantly moderate treatment outcome because the treatment approach draws upon values that reflect the dominant society. Individuals who have high enculturation may have high, medium, or low levels of acculturation to dominant society; the latter may be more relevant to response to treatments developed from dominant society values. Further, irrespective of enculturation levels, parents low on acculturation to majority US culture are likely to experience more acculturative stress and discrimination than parents high on acculturation, which potentially could have an impact on parenting and the parent-youth relationship. The present study was designed to shed light on these possible moderation effects.

Methods

Participants

The present sample of 139 Latino participants (67 female) and their parents (usually mother) was drawn from a larger RCT conducted in an urban area of south Florida where the majority of the population identifies as Latino/a (Silverman et al., 2017). Of the 246 youth participants enrolled in the RCT, approximately 75% completed treatment – a rate comparable to past trials (Silverman, Pina, & Viswesvaran, 2008). All 139 treatment completer youth that were Latino (76%) were retained for the present study. Youth participants ranged in age from 6 to 16 years (M = 9.68, SD = 2.19). There were no significant differences on demographic variables, acculturation levels, clinical variables at pretreatment, or condition assignment between treatment completers and non-completers. Results reported are based on treatment completer data (n = 139). Intent to treat (ITT) analyses yielded the same conclusions.

Annual household income was as follows: 17% below $21,000, 42% between $21,000 and $60,999, 19% between $61,000 and $99,999, and 16% over $100,000. The remaining 6% declined to report income. Over 75% of parents were married and approximately 35% had a bachelor’s degree or higher. Approximately 75% of parents were born outside the US and 70% elected to complete measures and interviews in Spanish. US nativity status was not significantly associated with education level for mothers (χ2(11) = 17.60, p < .05) or fathers (χ2(12) = 14.72, p < .05), but was significantly associated with levels of acculturation for mothers (t(107) = 4.53, p < .001) and fathers (t(105) = 3.59, p = .001), such that parents born outside the US had lower levels of acculturation compared with parents born in the US. Of parents born outside the US, the most common countries/regions of origin were Cuba (45%), South America (i.e., Colombia, Peru, Venezuela; 27%), Central America (i.e., Nicaragua, Honduras, Costa Rica; 19%), Puerto Rico (4%) and Mexico (3%). Approximately 80% of youth were born in the US and 96% of youth elected to complete measures and interviews in English. Of youth born outside the US, the most common countries/regions of origin were Cuba (13%), South America (i.e., Venezuela, Peru, Argentina; 61%), Central America (Nicaragua; 4%), Puerto Rico (17%), and Mexico (4%).

To enroll in the trial, youth were required to meet criteria for a primary diagnosis of a DSM-IV anxiety disorder. The most common primary diagnoses were separation anxiety disorder (33%), social anxiety disorder (23%), generalized anxiety disorder (18%), and specific phobia (17%). Youth with pervasive developmental disorders, intellectual disability, organic mental disorders, or psychotic disorders were excluded, as were youth engaged in concurrent psychosocial treatment. Youth receiving psychotropic medication were enrolled as long as the dose was stabilized prior to the start of treatment.

Procedure

Following parental consent and youth assent, families completed a pretreatment assessment. Participants who met inclusion criteria were randomly assigned to either GCBT or CBT/P in blocks of seven to account for the formation of groups. Both conditions followed manualized treatment approaches and consisted of 12 to 14 60-minute sessions. Treatment was provided by doctoral level graduate student therapists who were trained and supervised in English by a licensed clinical psychologist. We incorporated two relevant cultural factors in treatment, (1) language and (2) parental control, as these cultural factors could potentially impact treatment adherence and outcome. GCBT sessions were conducted in English, however, communication with Spanish-speaking parents regarding their child outside of sessions was conducted in Spanish by a Spanish-speaking counselor, and copies of written materials and assignments in Spanish were given to Spanish-speaking parents. Particular attention was devoted to word use and word meanings when translating handouts and treatment session content where the description of anxiety-related symptoms included terms such as nervios and ataques de nervios, common words used in the Latino community to describe fears and anxieties. CBT/P sessions were conducted in English or Spanish depending on the language preferences of parents and children. We often conducted CBT/P sessions in a bilingual format to accommodate parental preference for Spanish and youth preference for English. There were no statistically significant differences in any outcome variables between parents who preferred to have treatment in Spanish and those who preferred treatment in English. With regards to parental control, in CBT/P where parental control and the parent-child interaction were treatment targets, parental control and autonomy granting were discussed within a cultural framework (e.g., differentiating parental control from care and protection), and presenting alternatives to parental psychological control that fostered a sense of personal competency while also maintaining respeto.

GCBT

Youth anxiety symptoms were targeted in a group format using exposures and cognitive restructuring strategies consistent with CBT approaches. GCBT also specifically targeted increasing (1) positive peer-youth relationships and (2) youth social skills. Therapists assisted group participants in identifying positive peer-youth behaviors (e.g., getting together with peers) and social skills (e.g., approach peer; invite peer to do something with him/her) for targeting. Therapists modeled and conducted peer role-plays when targeting (1) and (2). Youth in GCBT groups were of mixed ethnicity: 82.1% Latino, 13.1% European-American, and 2.4% African-American. Only youths who identified as Latino were included in the present report.

CBT/P

Youth anxiety symptoms were targeted with youth and parent using exposures and cognitive restructuring techniques consistent with CBT approaches. CBT/P also targeted decreasing (1) negative parent-youth relationships and (2) parental psychological control. Therapists assisted youths and parents in identifying negative or problematic parent-child behaviors (e.g., youth noncompliance to parental requests) and parental psychological control behaviors (e.g., parent guilt induction) for targeting. Therapists modeled and conducted parent-child role-plays when targeting (1) and (2).

Measures

ADIS-IV: C/P (Silverman & Albano, 1996)

The ADIS-IV: C/P was administered to youths and parents, respectively, to derive youth diagnoses. The disorder deemed most interfering/impairing was considered ‘primary’ and was targeted in treatment. The ADIS-IV: C/P yields retest reliability kappas between .80 to .92 for combined youth and parent diagnoses including in samples comprised primarily of Latino participants for both English (e.g., Silverman, Saavedra, & Pina, 2001) and Spanish (Pina & Silverman, 2004) versions, and significant associations with youth anxiety ratings (e.g., Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). Two-week retest kappa coefficients for anxiety disorder diagnoses in 20% of this sample were .77 or higher.

Youth Anxiety Symptoms

The Revised Children’s Manifest Anxiety Scale Child and Parent versions (RCMAS-C/P; Reynolds & Richmond, 1985) are 37-item youth-rated and parent-rated measures of youth anxiety symptoms. Reliability and validity of the RCMAS-C/P have received extensive support, including in samples of Latino participants (see Pina, Little, Knight, & Silverman, 2009). Similarly, the Spanish versions of the RCMAS have demonstrated comparable psychometric properties to the English version in multiple studies (e.g., Varela, Sanchez-Sosa, Biggs, & Luis, 2008). In the present sample, coefficient alpha at pretreatment assessment was .89 for the RCMAS-C and .86 for the RCMAS-P.

Parental Acculturation

Parental acculturation level was assessed using the Stephenson Multigroup Acculturation Scale (SMAS; Stephenson, 2000), a 32-item self-rating measure of ethnic society immersion (ESI) and dominant society immersion (DSI). The DSI scale measures acculturation to the majority culture of the US and the ESI scale measures identification with the country of origin culture on the basis of language (e.g., understanding, fluency, spoken at home), familiarity with cultures (e.g., history, current affairs), and interactions with cultures (e.g., food, customs, social interactions), as well as reported levels of comfort interacting with cultures. Examples of DSI scale items include: “I speak English at home” and “I feel at home in the United States” (Stephenson, 2000). Examples of ESI scale items include: “I like to speak my native language” and “I attend social functions with people from my native country”. Convergent validity has been supported by significant associations with other measures of acculturation (Stephenson, 2000). Internal reliability has been estimated at .74 for the DSI scale and .82 for the ESI scale (Schwartz et al., 2013). For the present study, we used the English version of the SMAS and translated the SMAS into Spanish following guidelines recommended by Canino and Bravo (1994). In the present sample, coefficient alpha at the pretreatment assessment for the DSI scale was .88 and for the ESI scale was .78.

Parental Psychological Control

Parental psychological control (PC) was assessed using the PC subscale of the Child Report of Parental Behavior Inventory (CRPBI; child version) and the Parent Report of Parental Behavior Inventory (PRPBI; parent version; Schludermann & Schludermann, 1970). Youths and parents provide ratings on 30 items on a 3-point Likert scale, indicating whether that statement is “Not like”, “Somewhat like”, or “A lot like” the mother’s behavior toward the youth. Sample items from the parent version include: “I tell my child of all the things I have done for him/her” and “I am always telling my child how he/she should behave.” In the present sample, internal consistency was .76 and .78, for youth and parent report, respectively.

Results

Preliminary Analyses

Data for continuous variables were evaluated for multivariate outliers using both model and non-model based analyses. There were no outliers found. Analyses were conducted in the MPlus 7.0 statistical software program (Muthén & Muthén, 1998–2012) in a structural equation modeling (SEM) framework.

The rate of missing data was as follows: SMAS (21.58%), RCMAS posttreatment (13%), and RCMAS-P posttreatment (5%). Missing data bias was assessed by creating a dummy variable reflecting the presence or absence of missing data for each variable and then correlating it with all other variables. No meaningful bias was observed. Missing data were accommodated using full-information maximum-likelihood (FIML) estimation. Given that the GCBT condition contained 19 separate treatment groups, the analyses were adjusted for potential clustering effects (Baldwin, Murray, & Shadish, 2005). Participants in the CBT/P condition were grouped as one cluster for a total of 20 clusters.

Based on past research using the same measure of acculturation (Stephenson, 2000), the present sample’s mean acculturation scores fell between first and second generation immigrants. Parental acculturation and enculturation were not significantly associated with youth age, or parent education, and parental education did not vary by country of origin. Parental acculturation and enculturation did not significantly interact with youth age to predict outcomes.

Correlations

Pearson correlations were obtained for the following variables: income, youth and parent reports of anxiety (RCMAS) at pre and posttreatment, parental acculturation and enculturation, and youth and parent reports of parental psychological control at pretreatment (see Table 1 for correlations).

Table 1.

Correlation matrix

Income C-Anx-pr C-Anx-po P-Anx-pr P-Anx-po DSI ESI P-PC-pr P-PC-po C-PC-pr C-PC-po
Income 1
C-Anx-pr 0.017 1
C-Anx-po 0.094 0.493** 1
P-Anx-pr −0.032 0.146 0.170* 1
P-Anx-po 0.081 0.090 0.276* 0.556** 1
DSI 0.490** 0.031 0.091 0.067 −0.039 1
ESI −0.125 −0.082 −0.058 −0.041 −0.031 −0.229* 1
P-PC-pr −0.212* 0.075 −0.017 0.104 0.048 −0.296** 0.118 1
P-PC-po −0.275* 0.009 0.048 0.073 0.114 −0.336** 0.134 0.669** 1
C-PC-pr −0.086 0.271* 0.192* −0.130 0.041 −0.098 0.036 0.136 0.126 1
C-PC-po −0.059 0.254** 0.266* −0.041* 0.126 −0.063 −0.011 0.186* 0.297** 0.604** 1
Open in a new tab

C-Anx-pr = RCMAS youth report at pretreatment; C-Anx-po = RCMAS youth report at posttreatment; P-Anx-pr = RCMAS parent report at pretreatment; P-Anx-po = RCMAS parent report at posttreatment; DSI = parental acculturation; P-PC-pr = parental report of parental control at pretreatment; P-PC-po = parental report of parental control at postreatment; C-PC-pr = youth report of parental control at pretreatment; C-PC-po = youth report of parental control at postreatment

*

p<.05;

**

p<.001

Outcome Analyses

There were statistically significant pre to posttreatment changes in anxiety on the RCMAS-Child, χ2(1) = 81.01, p < .001, and RCMAS-Parent, χ2(1) = 218.01, p < .001, with no significant treatment condition by time interactions. For psychological control, there was a statistically significant pretreatment to posttreatment decrease, χ2(1) = 11.694, p < .001, with no significant treatment condition by time interactions. These findings are consistent with findings from the full sample as reported in Silverman et al. (2017).

Moderation Analyses

A series of multiple regression analyses were conducted that predicted post youth anxiety scores from treatment condition (GCBT, CBT/P) and parent acculturation scores. Of interest was whether differences between treatment conditions on self-rated and parent-rated post anxiety scores varied as a function of parental acculturation to majority US culture as measured by the DSI and parental identification with country of origin culture as measured by the ESI. DSI scores ranged from 26 to 63 (M=51.06; SD=9.49) and ESI scores ranged from 21 to 61 (M=53.13; SD=6.93). Prior to running analyses, continuous variables (including DSI and ESI) were mean centered to reduce the potential for multicollinearity and to facilitate interpretation of parameter estimates. The treatment conditions (GCBT vs. CBT/P) were dummy coded (i.e., GCBT = 0; CBT/P = 1). Product terms were generated to examine moderation by multiplying the treatment condition by the mean centered DSI or ESI scores (Jaccard & Turrisi, 2003). All predictor variables were entered into each regression equation simultaneously. Pretreatment anxiety scores were included as a covariate in all analyses. Child age, sex, and maternal education were added to the model as covariates. Results are presented without the inclusion of demographic covariates (age, sex, education) for ease of presentation.

ESI did not significantly moderate treatment outcome for parent-rated (B = .21, SE = .12, p>.05, 95% CI = −.03 to .45) or youth self-rated (B = −01, SE = .16, p>.05, 95% CI = −.33 to .32) youth anxiety. For self-rated youth anxiety, DSI did significantly moderate treatment outcome (B = −.05, SE = .11, p>.05, 95% CI = −.26 to .15). For parent ratings of youth anxiety, DSI significantly moderated treatment outcome, (B = −.21, SE = .06, p<.01, 95% CI = −.32 to −.09). See Table 2 for the regression coefficients and associated statistics for analyses with DSI. The mean RCMAS difference between GCBT and CBT/P changed by −.21 units for every one unit increase in DSI scores (see Table 2). The global effect size (i.e., of the model as a whole) was large, f 2 = .56, and the local effect size (i.e., specific to the interaction term), was small, f 2 = .05.

Table 2.

Regression Coefficients and Associated Statistics

Predictor B SE Z p value
Youth ratings of anxiety
RCMAS pre .47 .06 8.46 .000
DSI .08 .10 .73 .467
GCBT vs CBT/P −0.00 .92 −1.08 .279
Treatment × DSI −.05 .11 −.50 .615
Parent ratings of anxiety
RCMAS parent pre .53 .06 9.27 .000
DSI .08 .06 1.40 .163
GCBT vs CBT/P .10 .37 .28 .783
Treatment × DSI −.21 .06 −3.62 .000
Open in a new tab

Note: GCBT=Group Cognitive Behavioral Therapy; CBT/P= Cognitive Behavioral Therapy with Parent involvement; DSI= Dominant Society Immersion; RCMAS = Revised Children’s Manifest Anxiety Scale.

As shown in Figure 1, when DSI was above the mean, indicating high parental acculturation, youth in CBT/P had lower RCMAS-P post scores compared to youth in GCBT. When DSI was below the mean, indicating low levels of parental acculturation, youth who were in GCBT had lower RCMAS-P post scores compared to youth in CBT/P.

Figure 1. Differences in RCMAS parent post scores between treatment conditions at selected values of DSI.

Figure 1

Open in a new tab

Note: GCBT=Group Cognitive Behavioral Therapy; CBT/P= Cognitive Behavioral Therapy with Parent involvement; DSI= Dominant Society Immersion; RCMAS = Revised Children’s Manifest Anxiety Scale. *p < .05

Discussion

The findings of the present study add to a literature documenting significant reductions in anxiety in response to CBTs in Latino youth. Consistent with most comparative studies of CBTs for youth anxiety disorders (e.g., Silverman et al., 2008; Thulin et al., 2014), no significant overall differences in anxiety outcomes were found in this study between peer-involved GCBT and CBT/P in both parent ratings of their child’s anxiety and youths’ self ratings of anxiety. Importantly, consistent with our hypothesis, parental acculturation to majority US culture, but not identification with country of origin culture, significantly moderated treatment outcome based on parent ratings of youth anxiety. At low levels of acculturation (i.e., when parents were less acculturated to majority society), they reported their children as showing superior treatment outcome in group-delivered CBT targeting peer relationship variables than in parent-involved CBT targeting parental psychological control and negative parent-youth relationships. At high levels of acculturation (i.e., when parents were more acculturated to majority society), they reported their children as showing superior treatment outcome in parent-involved CBT than peer-involved GCBT.

Significant moderation effects were not found on youth self-ratings of anxiety. Discrepant findings across parent and youth ratings are common in the child anxiety treatment literature and highlight the importance of multisource assessment. Our results suggest parental acculturation levels are related to how parents perceive their child’s anxiety reduction in treatments that target parent variables versus peer variables, but not to how youth perceive their own anxiety reduction in different CBTs. Although it is possible shared source variance could contribute to the significant effect for parent ratings, data are not consistent with this possibility: the correlation coefficient between parental acculturation and parental ratings of youth anxiety was small and not statistically significant (r = .07, p = ns). It will be important for future research to also include independent evaluator ratings of youth anxiety reduction.

The present findings could have implications for selecting treatment targets and delivery format when working with Latino youth with anxiety disorders. Specifically, CBT outcomes may be enhanced if clinicians assess parental acculturation levels to majority US values and then select a CBT (GCBT or CBT/P) that best matches parental acculturation levels. When Latino youth have parents who are highly acculturated, explicitly targeting parenting variables such as parental psychological control and the parent-youth relationship may produce superior treatment response compared with a peer group treatment approach. Inversely, for Latino youth with parents who are low on acculturation, superior treatment outcomes may be achieved by explicitly targeting peer relationship variables instead, such as the youth’s social skills in the context of peer relationships. In the latter scenario, parents would still be involved in the treatment process, as they are regularly questioned about their child’s functioning and updated on their child’s treatment progress. Further, parents would be involved by facilitating practice and exposures at home, and reporting progress and barriers back to their therapists. However, parental psychological control and parent-youth relationship variables would not be the primary focus of treatment.

It is possible that targeting other variables in CBT/P, such as parental warmth or familial stressors, may lead to enhanced outcomes in Latino families with less acculturated parents, but the present study did not address that possibility. For example, there is evidence that targeting parenting practices may lead to superior youth outcomes in Latinos, at least in the treatment for PTSD (Santiago et al., 2014). The present findings should not be interpreted as contraindicating parental involvement in youth treatment in less acculturated families; rather, it will be important to identify the optimal ways to involve less acculturated parents in the treatment of youth anxiety. More broadly, these findings are consistent with the axiom that not all treatments work equally well for all Latino families, and clinicians need to be attuned to specific cultural characteristics of families that may impact treatment response. We encourage future studies to investigate additional moderators that may be used to personalize treatment approaches for Latino youth with anxiety disorders. We also encourage future studies to replicate our findings while identifying acculturation cut-offs that could be used to select treatments.

We proposed that interventions targeting reductions in parental psychological control might be incongruent with the values, traditions, and parenting practices of Latino parents who have not adopted majority U.S. cultural values. A poor congruence between treatment goals and cultural values (e.g., cultural match) may impede progress on the targeted variable (parental psychological control) and subsequent outcome variable (youth anxiety; e,g., La Roche et al., 2014). Although the present findings are consistent with this notion, we were not able to explicitly test whether a perceived incongruence between parenting values and treatment targets influenced treatment outcomes. We encourage future research to explicitly test this proposal and to evaluate whether targeting other parenting behaviors in CBT/Ps may lead to enhanced outcomes when parental acculturation is low. We also found that an intervention targeting parental psychological control and negative parent-youth relationships led to superior youth anxiety reduction than an intervention targeting peer relationships when parents had adopted majority U.S. cultural values (i.e., parents high in acculturation). We did not predict this effect. Further investigation will be needed to examine whether this unpredicted finding replicates, and if so, to consider possible explanations of it. We speculate one possibility may be that highly acculturated Latino parents found CBT/P congruent with their parenting values and beliefs, and this congruence may have resulted in superior treatment outcome. However, we were not able to test this possibility in the present study.

We did not find a significant association between youth age and parental acculturation and the interaction between age, parental acculturation, and treatment condition was not statistically significant. A possible explanation for these non-significant findings could be that our sample had a fairly narrow age range, and thus differences might not be as meaningful as if we were comparing younger children with adolescents. Future research should consider how parental acculturation might be differentially important as children age.

The findings of this study should be interpreted in light of its strengths and limitations. Strengths include the randomized controlled trial design with a large number of Latino participants, the use of manualized treatment approaches, and the use of semi-structured diagnostic interviews and rating scales administered to parents and youth. However, only one parent completed questionnaires and was involved in CBT/P, almost always the mother. This approach excluded the perspective of the other parent. In Latino families, there is evidence the association between parental control and youth anxiety severity differs for mothers and fathers (Varela, Sanchez-Sosa, Biggs, & Luis, 2009), highlighting the potential value in collecting data from both parents. Another limitation was the exclusive focus on symptom reduction as an outcome. Future research should include assessments of general functioning and quality of life. We did not collect data on contextual factors that could have impacted youth anxiety and treatment outcome, such as time of foreign-born parents spent in the US and generation status of US-born parents, previous mental health treatment, or data regarding stressors Latinos face, particularly in the process of acculturation. Discrimination, limited English language proficiency, and acculturative stress might influence not only the development and maintenance of youth anxiety, but might also influence the way in which families respond to treatment.

Our sample was relatively highly educated and drawn from an urban area in south Florida wherein the majority of the population identifies as Latino. Because areas of south Florida can be considered ethnic enclaves, pressure to acculturate to mainstream US culture and experiences of acculturative stress and discrimination may be lower compared with other regions of the US. The generalizability of the present findings to Latinos residing in other regions of the US, especially outside of ethnic enclaves, is unknown. The majority of parents in our sample were foreign born, with Cuba, South American, and Central American countries being the most common countries of origin. Latinos in the US are a heterogeneous population, with different immigration histories, socialization patterns, and cultural values that influence parenting practices. Aside from the large number of Cubans in our sample, the size of each subgroup was too small to conduct tests to evaluate within-group cultural differences at the country level. It will be important for future research to investigate the generalizability of the present findings.

Despite these limitations, the present study provides support for parental acculturation as a moderator of youth anxiety CBT outcome in Latino youth. These findings provide empirical guidance for selecting CBT targets and delivery format based on parental acculturation levels, with an eye toward enhancing youth anxiety outcomes.

Acknowledgments

This research was supported in part by funding provided by R01 MH63997 awarded to Wendy K. Silverman and by funding provided by NIH/NIGMS R25 GM061347 awarded to Daniella Vaclavik. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Contributor Information

Daniella Vaclavik, Florida International University.

Victor Buitron, Florida International University.

Yasmin Rey, Florida International University.

Carla E. Marin, Yale University School of Medicine, Child Study Center

Wendy K. Silverman, Yale University School of Medicine, Child Study Center

Jeremy W. Pettit, Florida International University

References

  1. Baldwin SA, Murray DM, Shadish W. Empirically supported treatments or Type I errors? Problems with the analysis of data from group-administered treatments. Journal of Consulting and Clinical Psychology. 2005;73(5):924–935. doi: 10.1037/0022-006X.73.5.924. [DOI] [PubMed] [Google Scholar]
  2. Barber BK. Parental Psychological Control: Revisiting a Neglected Construct. Child Development. 1996;67:3296–3319. [PubMed] [Google Scholar]
  3. Beidel DC, Turner SM, Morris TL. Behavioral treatment of childhood social phobia. Journal of Consulting and Clinical Psychology. 2000;68(6):1072–1080. [PubMed] [Google Scholar]
  4. Calzada EJ, Tamis-LeMonda C, Yoshikawa H. Familismo in mexican and dominican families from low-income, urban communities. Journal of Family Issues. 2013;34(12):1696–1724. [Google Scholar]
  5. Canino G, Bravo M. The adaptation and testing of diagnostic and outcome measures for cross-cultural research. International Review of Psychiatry. 1994;6:281–286. [Google Scholar]
  6. Capielo C, Delgado-Romero EA, Stewart AE. A focus on an emerging Latina/o population: The role of psychological acculturation, acculturative stress, and coping on depression symptoms among central Florida Puerto Ricans. Journal of Latina/o Psychology. 2015;3(4):209–223. [Google Scholar]
  7. Cohen JA, Bukstein O, Walter H, Benson RS, Chrisman A, Farchione TR, Medicus J. Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress. Journal of the American Academy of Child & Adolescent Psychiatry. 2010;49:414–430. [PubMed] [Google Scholar]
  8. Compton SN, Peris TS, Almirall D, Birmaher B, Sherrill J, Kendall PC, March JS, Gosch EA, Ginsburg GS, Rynn MA. Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial. Journal of Consulting and Clinical Psychology. 2014;82:212–224. doi: 10.1037/a0035458. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. De Los Reyes A, Augenstein TM, Wang M, Thomas SA, Drabick DAG, Burgers DE, Rabinowitz J. The validity of the multi-informant approach to assessing child and adolescent mental health. Psychological Bulletin. 2015;141(4):858–900. doi: 10.1037/a0038498. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Domenech-Rodríguez MM, Donovick MR, Crowley SL. Parenting styles in a cultural context: Observations of “protective parenting” in first-generation Latinos. Family Process. 2009;48(2):195–210. doi: 10.1111/j.1545-5300.2009.01277.x. [DOI] [PubMed] [Google Scholar]
  11. Driscoll AK, Russell ST, Crockett LJ. Parenting styles and youth well-being across immigrant generations. Journal of Family Issues. 2008;29(2):185–209. [Google Scholar]
  12. Durrett ME, O’Bryant S, Pennebaker JW. Child-rearing reports of White, Black, and Mexican-American families. Developmental Psychology. 1975;11(6) [Google Scholar]
  13. Guilamo-Ramos V, Dittus P, Jaccard J, Johansson BA, Acosta N. Parenting practices among Dominican and Puerto Rico mothers. Social Work. 2007;52:17–30. doi: 10.1093/sw/52.1.17. [DOI] [PubMed] [Google Scholar]
  14. Gerull FC, Rapee RM. Mother knows best: effects of maternal modelling on the acquisition of fear and avoidance behaviour in toddlers. Behaviour Research and Therapy. 2002;40(3):279–87. doi: 10.1016/s0005-7967(01)00013-4. [DOI] [PubMed] [Google Scholar]
  15. Gudykunst WB. Bridging differences: Effective intergroup communication. Newbury Park, CA: Sage; 1998. [Google Scholar]
  16. Halgunseth LC, Ispa JM, Rudy D. Parental control in Latino families: An integrated review of the literature. Child Development. 2006;77:1282–1297. doi: 10.1111/j.1467-8624.2006.00934.x. [DOI] [PubMed] [Google Scholar]
  17. Jaccard J, Turrisi R. Interaction effects in multiple regression. 2nd. Thousand Oaks, CA: Sage; 2003. [Google Scholar]
  18. Julian TW, McKenry PC, McKelvey MW. Cultural variations in parenting: Perceptions of Caucasian, African-American, Hispanic, and Asian-American parents. Family Relations. 1994;43:30–37. [Google Scholar]
  19. Knight GP, Virdin LM, Roosa M. Socialization and Family Correlates of Mental Health Outcomes among Hispanic and Anglo American Children: Consideration of Cross-Ethnic Scalar Equivalence. Child Development. 1994;65(1):212–224. doi: 10.1111/j.1467-8624.1994.tb00745.x. [DOI] [PubMed] [Google Scholar]
  20. La Roche M, Batista C, D’Angelo E. A culturally competent relaxation intervention for low-income Latino/as: An exploratory study. Journal of Latina/o Psychology. 2014;2(3):146–155. [Google Scholar]
  21. Lawton KE, Gerdes AC. Acculturation and latino adolescent mental health: Integration of individual, environmental, and family influences. Clinical Child and Family Psychology Review. 2014;17:385–398. doi: 10.1007/s10567-014-0168-0. [DOI] [PubMed] [Google Scholar]
  22. Luis T, Varela RE, Moore K. Parenting practices and childhood anxiety reporting: A comparison of Mexican, Mexican American, and European American youth. Journal of Anxiety Disorders. 2008;22:1011–1020. doi: 10.1016/j.janxdis.2007.11.001. [DOI] [PubMed] [Google Scholar]
  23. McLeod B, Wood JJ, Weisz JR. Examining the association between parenting and childhood anxiety: A meta-analysis. Clinical Psychology Review. 2007;27:155–172. doi: 10.1016/j.cpr.2006.09.002. [DOI] [PubMed] [Google Scholar]
  24. Motoca LM, Williams S, Silverman WK. Social skills as a mediator between anxiety symptoms and peer interactions among children and adolescents. Journal of Clinical Child & Adolescent Psychology. 2012;41(3):329–336. doi: 10.1080/15374416.2012.668843. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Muthén LK, Muthén BO. Mplus user’s guide. Seventh. Los Angeles, CA: Muthén & Muthén; 1998–2012. [Google Scholar]
  26. National comorbidity survey, Adolescent. Harvard Medical School. 2005 Retrieved from http://www.hcp.med.harvard.edu/ncs/index.php.
  27. Pina AA, Little M, Knight GP, Silverman WK. Cross-ethnic measurement equivalence of the RCMAS in Latino and white youth with anxiety disorders. Journal of Personality Assessment. 2009;91:58–61. doi: 10.1080/00223890802484183. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Pina AA, Silverman WK. Clinical phenomenology, somatic symptoms, and distress in Hispanic/Latino and European American youths with anxiety Disorders. Journal of Clinical Child & Adolescent Psychology. 2004;33(2):227–236. doi: 10.1207/s15374424jccp3302_3. [DOI] [PubMed] [Google Scholar]
  29. Pina AA, Silverman WK, Fuentes RM, Kurtines WM, Weems CF. Exposure-based cognitive behavioral treatment for phobic and anxiety disorders: Treatment effects and maintenance for Hispanic American relative to Euro-American youths. Journal of the American Academy of Child and Adolescent Psychology and Psychiatry. 2003;42:1179–1187. doi: 10.1097/00004583-200310000-00008. [DOI] [PubMed] [Google Scholar]
  30. Pina AA, Zerr AA, Villalta IK, Gonzales NA. Indicated prevention and early intervention for childhood anxiety: A randomized trial with Caucasian and Hispanic/Latino youth. Journal of Consulting and Clinical Psychology. 2012;80(5):940–946. doi: 10.1037/a0029460. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Rapee RM. Family factors in the development and management of anxiety disorders. Clinical Child and Family Psychology Review. 2012;15(1):69–80. doi: 10.1007/s10567-011-0106-3. [DOI] [PubMed] [Google Scholar]
  32. Reynolds CR, Richmond BO. Revised children’s manifest anxiety scale: manual. Los Angeles, CA: Western Psychological Services; 1985. [Google Scholar]
  33. Roosa MW, Weaver SR, White RMB, Tein JY, Knight GP, Gonzales N, Saenz D. Family and Neighborhood Fit or Misfit and the Adaptation of Mexican Americans. American Journal of Community Psychology. 2009;44(1–2):15–27. doi: 10.1007/s10464-009-9246-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Ryder AG, Alden LE, Paulhus DL. Is acculturation unidimensional or bidimensional? A head-to-head comparison in the prediction of personality, self-identity, and adjustment. Journal of Personality and Social Psychology. 2000;79:49–65. doi: 10.1037//0022-3514.79.1.49. [DOI] [PubMed] [Google Scholar]
  35. Santiago CD, Lennon JM, Fuller AK, Brewer SK, Kataoka SH. Examining the impact of a family treatment component for CBITS: When and for whom is it helpful? Journal of Family Psychology. 2014;28(4):560–570. doi: 10.1037/a0037329. [DOI] [PubMed] [Google Scholar]
  36. Schludermann E, Schludermann S. Replicability of factors in children’s report of parent behavior (CRPBI) Journal of Psychology. 1970;76:239–249. [Google Scholar]
  37. Schludermann E, Schludermann S. Unpublished manuscript. Department of Psychology, University of Manitoba; Winnipeg, Canada: 1988. Children’s Report on Parent Behavior (CRPBI-108, CRPBI-30) [Google Scholar]
  38. Schwartz SJ, Waterman AS, Umaña‐Taylor AJ, Lee RM, Kim S, Vazsonyi AT, Williams MK. Acculturation and well‐being among college students from immigrant families. Journal Of Clinical Psychology. 2013;69(4):298–318. doi: 10.1002/jclp.21847. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Silverman WK, Albano A. The Anxiety Disorders Interview Schedule for Children–IV (Child and parent versions) San Antonio, TX: Psychological Corporation; 1996. [Google Scholar]
  40. Silverman WK, Kurtines WM, Jaccard J, Pina AA. Directionality of change in youth anxiety treatment involving parents: An initial examination. Journal of Consulting and Clinical Psychology. 2009;77:474–485. doi: 10.1037/a0015761. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Silverman WK, Marin CE, Rey Y, Jaccard J, Pettit JW. Cognitive behavior therapy (CBT) with parent involvement and group CBT for anxiety disorders in youth: Treatment effects, specificity, mediation, and directionality. 2017 Manuscript submitted for publication. [Google Scholar]
  42. Silverman WK, Pina AA, Viswesvaran C. Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology. 2008;37(1):105–130. doi: 10.1080/15374410701817907. [DOI] [PubMed] [Google Scholar]
  43. Silverman WK, Saavedra LM, Pina AA. Test–retest reliability of anxiety symptoms and diagnoses with Anxiety Disorders Interview Schedule for DSM–IV: Child and Parent versions. Journal of the American Academy of Child and Adolescent Psychiatry. 2001;40:937–944. doi: 10.1097/00004583-200108000-00016. [DOI] [PubMed] [Google Scholar]
  44. Smokowski P, Buchanan RL, Bacallao ML. Acculturation and Adjustment in Latino Adolescents: How Cultural Risk Factors and Assets Influence Multiple Domains of Adolescent Mental Health. The Journal of Primary Prevention. 2009;30:371–393. doi: 10.1007/s10935-009-0179-7. [DOI] [PubMed] [Google Scholar]
  45. Smokowski PR, Rose RA, Evans CBR, Cotter KL, Bower M, Bacallao M. Familial influences on internalizing symptomatology in Latino adolescents: An ecological analysis of parent mental health and acculturation dynamics. Development and Psychopathology. 2014;26:1191–1207. doi: 10.1017/S0954579414000960. [DOI] [PubMed] [Google Scholar]
  46. Staples R, Mirande A. Racial and cultural variations among American families: a decennial review of the literature on minority families. Journal of Marriage and the Family. 1980;42:887–903. [Google Scholar]
  47. Stein GL, Guzman LE. Prevention and Intervention Research With Latino Families: A Translational Approach. Family Process. 2015;54(2):280–292. doi: 10.1111/famp.12143. [DOI] [PubMed] [Google Scholar]
  48. Stephenson M. Development and Validation of the Stephenson Multigroup Acculturation Scale (SMAS) Psychological Assessment. 2000;12:77–88. [PubMed] [Google Scholar]
  49. Thulin U, Svirsky L, Serlachius E, Andersson G, Ost LG. The effect of parent involvement in the treatment of anxiety disorders in children: a meta-analysis. Cognitive Behavior Therapy. 2014;43(3):185–200. doi: 10.1080/16506073.2014.923928. [DOI] [PubMed] [Google Scholar]
  50. United States Census Bureau. 2013 Retrieved from https://www.census.gov/newsroom/facts-for-features/2015/cb15-ff18.html.
  51. U.S. Department of Health and Human Services. Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; 2001. [Google Scholar]
  52. Varela RE, Niditch LA, Hensley-Maloney L, Moore KW, Creveling CC. Parenting Practices, Interpretive Biases, and Anxiety in Latino Children. Journal of Anxiety Disorders. 2013;27:171–177. doi: 10.1016/j.janxdis.2012.12.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Varela RE, Hensley-Maloney L. The Influence of Culture on Anxiety in Latino Youth: A Review. Clinical Child and Family Psychology Review. 2009;12:217–233. doi: 10.1007/s10567-009-0044-5. [DOI] [PubMed] [Google Scholar]
  54. Varela RE, Sanchez-Sosa JJ, Biggs BK, Luis TM. Anxiety Symptoms and Fears in Hispanic and European American Children: Cross-Cultural Measurement Equivalence. Journal of Psychopathology and Behavioral Assessment. 2008;30(2):132–145. [Google Scholar]
  55. Varela RE, Sanchez-Sosa J, Biggs BK, Luis TM. Parenting strategies and socio-cultural influences in childhood anxiety: Mexican, Latin-American descent, and European-American families. Journal of Anxiety Disorders. 2009;23(5):609–616. doi: 10.1016/j.janxdis.2009.01.012. [DOI] [PubMed] [Google Scholar]
  56. Varela RE, Vernberg EM, Sanchez-Sosa JJ, Riveros A, Mitchell M, Mashunkashey J. Parenting practices of Mexican, Mexican American, and Caucasian-Non-Hispanic families: Social context and cultural influences. Journal of Family Psychology. 2004;18:651–657. doi: 10.1037/0893-3200.18.4.651. [DOI] [PubMed] [Google Scholar]
  57. Wood JJ, McLeod BD, Sigman M, Hwang WC, Chu BC. Parenting and childhood anxiety: Theory, empirical findings, and future directions. Journal of Child Psychology and Psychiatry. 2003;44:134–151. doi: 10.1111/1469-7610.00106. [DOI] [PubMed] [Google Scholar]
  58. Wood JJ, Piacentini JC, Bergman RL, McCracken J, Barrios V. Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM–IV: Child and Parent versions. Journal of Clinical Child and Adolescent Psychology. 2002;45:335–342. doi: 10.1207/S15374424JCCP3103_05. [DOI] [PubMed] [Google Scholar]

RESOURCES