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Treatment Acceptability Among Mexican American Parents
Behavior Therapy 38 (2007) 218–227 www.elsevier.com/locate/bt
Treatment Acceptability Among Mexican American Parents Joaquin Borrego, Elizabeth S. Ibanez, Stuart J. Spendlove, Joy R. Pemberton Texas Tech University
There is a void in the literature with regard to Hispanic parents’ views about common interventions for children with behavior problems. The purpose of this study was to examine the treatment acceptability of child management techniques in a Mexican American sample. Parents’ acculturation was also examined to determine if it would account for differences in treatment acceptability. Mexican American parents found response cost, a punishment-based technique, more acceptable than positive reinforcement– based techniques (e.g., differential attention). Results suggest that Mexican American parents’ acculturation has little impact on acceptability of child management interventions. No association was found between mothers’ acculturation and treatment acceptability. However, more acculturated Mexican American fathers viewed token economy as more acceptable than less acculturated fathers. Results are discussed in the context of clinical work and research with Mexican Americans.
H I S PA N I C S R E C E N T LY S U R PA S S E D A F R I C A N A M E R I C A N S as the largest ethnic minority group in the United States (U.S. Census Bureau, 2004). Despite this significant population increase, there continues to be a paucity of research related to mental health service delivery with Hispanics. This is crucial because research has consistently found that Hispanics tend to underutilize mental health services (U.S. We would like to thank Meghan M. Goodrich for feedback and editorial suggestions regarding the manuscript. This research was supported in part by a grant, College of Arts and Sciences, Texas Tech University. Portions of this research were presented at the 38th Annual Meeting of the Association for Advancement of Behavior Therapy, New Orleans, Louisiana. Address correspondence to Joaquin Borrego, Department of Psychology, Texas Tech University, Lubbock, TX 79409-2051, USA; e-mail: [email protected]. 0005-7894/07/0218–0227$1.00/0 © 2007 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
DHHS, 2001; Yeh et al., 2002), receive lesser quality mental health services (U.S. DHHS, 2001), and are generally dissatisfied with the quality of the services received (Alegria et al., 2002). Given this, it appears that the mental health system is not adequately prepared to meet the needs of Hispanics (McCabe et al., 1999). Though stigma of mental health services does seem to influence utilization patterns (Gary, 2005), Hispanics do utilize formal mental health services. When utilizing services, U.S.-born Mexican Americans are likely to seek services from either physicians or counselors (Vega, Kolody, & AguilarGaxiola, 2001). Research also suggests that relying on family and other social networks does not serve as a substitute for seeking formal mental health services (Vega & Alegria, 2001). Given the disparities in mental health care, it is paramount that clinical researchers continue to develop or adapt, implement, and evaluate mental health interventions that meet the psychosocial needs of these families by providing services that are culturally appropriate (American Psychological Association, 2003). This is especially true for parenting programs that target culturally diverse families (Forehand & Kotchick, 1996). One strategy in developing and providing culturally appropriate mental health services is to address issues related to social validity. According to Wolf (1978), a socially valid intervention is one that has meaning and value to a specific community. Wolf felt that it was important to get a community’s input when designing, implementing, and evaluating an intervention. As he argued, a community may not like or agree with an intervention, even when it has been shown to be effective. A community can be flexibly defined, ranging from a local neighborhood facing a particular problem (e.g., high crime rate) to a group of people sharing similar characteristics (e.g., Mexican American parents). Social validity can be evaluated at three levels: (a) the social significance of the goals (i.e., if clinicians were to identify
treatment acceptability among mexican american parents treatment goals, would Mexican American parents agree on the same treatment goals?); (b) the social appropriateness of the procedures implemented (i.e., would Mexican American parents consider a specific treatment acceptable?); and (c) the social importance of the effects (i.e., are Mexican American parents satisfied with the outcome?). Given this, examining social validity is relevant in the context of conducting and evaluating treatment research (Foster & Mash, 1999). The current study focuses on the second aspect of social validity: acceptability of treatment procedures. Treatment acceptability is defined in terms of the judgments made by potential consumers of a treatment about the appropriateness, fairness, reasonableness, and nonintrusiveness of treatment procedures (Kazdin, 1981). Providing acceptable treatments is important because it can lead to increased cooperation, compliance, and effectiveness of the intervention (Kazdin, 1980). Treatment factors such as efficacy (Adams & Kelley, 1992), intervention type (Heffer & Kelley, 1987), complexity or time to implement (Elliott, Witt, Galvin, & Peterson, 1984), and side effects (Kazdin, 1981) have been found to influence treatment acceptability judgments. However, treatment efficacy alone does not predict acceptability or effectiveness with diverse populations (Boothe, Borrego, Hill, & Anhalt, 2005). Additionally, client factors that influence treatment acceptability include the severity of behavior problems (Kazdin, 1981), marital distress (Miller & Kelley, 1992), and socioeconomic status (Kelley, Grace, & Elliott, 1990). Generally, the treatment acceptability literature has shown that reinforcement-based treatments are rated higher than punishment-based treatments. In other words, treatments focused on increasing prosocial behaviors (e.g., positive reinforcement for sharing) are rated higher than interventions that focus on decreasing negative behaviors (e.g., timeout for whining). As an example, Jones, Eyberg, Adams, and Boggs (1998) examined treatment acceptability in a clinic sample and found that mothers of children referred for services for socially disruptive behavior problems preferred reinforcement the most and spanking the least. Very few studies, however, have examined treatment acceptability with racial/ethnic minority populations. When comparing African American and Caucasian mothers from either low or middleupper income levels, Heffer and Kelley (1987) found that, regardless of race and income, mothers viewed response cost and positive reinforcement as acceptable child management strategies, but low-income mothers rated time-out significantly lower than
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middle-upper income mothers. The authors conducted further analyses to determine the degree to which mothers rated a treatment as moderately acceptable. The results suggest that fewer lowincome African American mothers were accepting of time-out than middle-upper income Caucasian and African American mothers. In addition, fewer middle-upper income Caucasian mothers were accepting of spanking than low-income Caucasian mothers, and low-income and middle-upper income African American mothers. Similar percentages of low and middle-upper income African American mothers rated spanking as acceptable. The Heffer and Kelly findings suggest that income levels and possibly race influence treatment acceptability ratings. Tarnowski, Simonian, Park, and Bekeny (1992) found that treatment acceptability ratings did not vary as a function of socioeconomic status between African American and Caucasian mothers. The authors did not find race to significantly affect treatment acceptability ratings. Unfortunately, the two studies cannot be compared due to assessment and operationalization differences. In summary, though there are numerous treatment acceptability studies, very few have focused on racial and ethnic minority populations. Of the few studies available, the focus has been on African Americans (e.g., Heffer & Kelly, 1987; Tarnowski et al., 1992). To date, no studies have examined treatment acceptability with Hispanics. Thus, it is not known what child management strategies Hispanic parents would find acceptable. There may be treatment acceptability differences that can influence different aspects of treatment (e.g., following through with treatment recommendations). As has been suggested, this is important to examine because culture and socialization play an important role in shaping parenting practices (Zayas & Solari, 1994). Because the term Hispanic is used as an umbrella term to encompass numerous subgroups, it would be erroneous to assume that this group is homogeneous. Hispanics, as a whole, are a very heterogeneous group comprised of different subgroups (e.g., Mexicans, Cubans, Puerto Ricans, Central and South Americans). Of the approximately 40 million Hispanics residing in the U.S., Mexican Americans comprise the largest subgroup at 64% (U.S. Census Bureau, 2004). There are significant Hispanic subgroup differences with regard to immigration patterns, customs, socioeconomic status, region settlement, language, and other cultural characteristics (De Von FigueroaMoseley, Ramey, Keltner, and Lanzi, 2006; Vega, 1995). As an example, there is recent research to suggest that Hispanic subgroups differ along different parenting dimensions (e.g., De Von
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Figueroa-Moseley et al. 2006; Planos, Zayas, & Busch-Rossnagel, 1995). In addition to subgroup differences, there may also be important within-subgroup differences. The construct of acculturation has received much attention as a means of trying to account for Hispanic within-group differences (Negy and Woods, 1992). Acculturation is a multidimensional sociocultural process whereby an individual experiences changes to varying degrees across different domains (Berry, 2003). Through coming in contact with the dominant culture, social and environmental processes shape various attitudes, beliefs, values, and behaviors. Acculturation includes changes at both the individual (psychological) and group (sociocultural) levels (Trimble, 2003). The assumption behind the acculturative process is that highly acculturated Hispanics (whether bicultural or assimilated) start adopting attitudes, values, and behaviors similar to Caucasians. Acculturation has been found to influence different processes, such as the cultural value of familism (Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987), childrearing (Delgado-Gaitan, 1993), socialization of children (Cousins, Power, & Olvera-Ezzell, 1993), and discipline strategies (Buriel, Mercado, Rodriquez, & Chavez, 1991). Unfortunately, there is no conclusive parenting (e.g., discipline) research on Hispanics on which to draw valid comparisons with Caucasians (Calzada and Eyberg, 2002). This might be due in part to the disagreement about the consistency of parenting styles and practices in Hispanic families (Hill, Bush, & Roosa, 2003). Not surprisingly, there are mixed findings with regard to Hispanic parenting practices in the literature. A good illustration is the differences found in parenting styles. Some studies have found that Hispanic parents are authoritarian (e.g., Zayas, 1992), while other studies have found that Hispanic parents report being more authoritative than authoritarian (Varela et al., 2004). There is also literature available regarding the use of more specific child management strategies by Hispanic parents. A study by Medora, Wilson, and Larson (2001) found similar parenting strategies between Caucasian, Hispanic, and African American mothers. Medora and colleagues found that all mothers listed spanking as the least preferable parenting strategy, whereas praise, reasoning, and differential attention were listed as highly preferable. This study was supported by Calzada and Eyberg (2002), who found that Hispanic mothers use high levels of praise and physical affection. Contrary to these studies, other research has found that Hispanic parents use physical discipline as a means of managing their child’s behavior and rely
less on praising their child (Knight, Virdin, & Roosa, 1994; Laosa, 1980). Research with Mexican-origin parents has found that child management strategies of native and foreign-born Mexican mothers differ depending on acculturation (Buriel et al., 1991). After controlling for socioeconomic status, Mexican American mothers preferred nonphysical discipline, whereas foreign-born Mexican mothers were more likely to endorse using spanking (Buriel et al.). As highlighted by this literature, no consistent pattern emerges with regard to Hispanic parenting. However, acculturation may be an important construct to consider when conducting research with Hispanics because of the potential within-subgroup variability that may exist. Including variables such as acculturation and specifying subgroups of Hispanic populations (e.g., Mexican Americans) may assist with interpreting some of the mixed findings in the literature. In treatment acceptability research with Hispanics, it may be necessary to assess acculturation as it may affect the degree to which parents find different treatments acceptable.
Purpose The purpose of this study was to assess treatment acceptability of common child management techniques among Mexican American parents and to examine whether acculturation has an impact on acceptability of different treatment strategies. We were interested in examining whether previous findings, that reinforcement-based techniques are generally more acceptable (Jones et al., 1998), would generalize to a Mexican American sample. The hypotheses were also based on previous research findings (e.g., Calzada & Eyberg, 2002; Medora et al., 2001) that Hispanics preferred and used positive reinforcement (e.g., praise) strategies. Given this, the following hypotheses were made: 1. Overall, reinforcement-based techniques (e.g., token economy and differential attention) would be rated as more acceptable than punishment-based techniques (e.g., response cost, spanking, and time-out) and medication. 2. As Mexican American parents increased in acculturation to Anglo-American culture, reinforcement-based techniques would be rated as more acceptable than punishment-based techniques and medication.
Method participants Participants consisted of a west Texas community sample of 97 Mexican American parents with
treatment acceptability among mexican american parents children between 2 and 8 years old. People of Mexican origin account for approximately 33% of the population in this midsize west Texas community. There were 63 mothers and 34 fathers. Mothers and fathers were from different families. Parents’ mean age was 33 years (SD = 8.22). Seventy-two percent of parents were married, 10% divorced, and 18% single/never been married. Parents’ education level was as follows: 34.4% had a high school degree and 32.3% had some college. Thirty-one percent of participants reported annual household incomes of less than or equal to $15,000. Please see Table 1 for detailed demographic information.
materials The following materials were available in Spanish and English but all 97 participants chose English versions. Demographics questionnaire. Demographic variables included the parent’s age, gender, income, marital status, education level, and ethnicity.
Table 1 Demographic Information
Gender of parent Male Female Parent’s marital status Single/never married Married Divorced Number of children 1 2 3 4+ Parent's education level Jr. high Some high school High school degree or GED Some college College degree Graduate degree Annual household income <15,000 15,000–25,000 25,001–50,000 >50,001 Missing Generation status 1st Generation 2nd Generation 3rd Generation 4th Generation 5th Generation
N
%
33 63
34.4 65.6
16 70 10
16.7 72.9 10.4
16 39 23 18
16.7 40.6 24.0 18.8
7 12 33 31 9 4
7.3 12.5 34.4 32.3 9.4 4.2
30 23 30 9 4
31.2 24.0 31.3 9.4 4.2
8 18 22 33 15
8.3 18.8 22.9 34.4 15.6
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Treatment evaluation inventory–short form. (TEI-SF; Kelley, Heffer, Gresham, & Elliott, 1989). The TEI-SF is a 9-question, 5-point Likert rating scale, ranging from “strongly disagree” to “strongly agree,” which is completed for each treatment alternative. Scores for each treatment option can range from a minimum of 9 to a maximum of 45. Kelley et al. (1989) found that the TEI-SF is an internally consistent and valid measure. The coefficient alpha was reported to be 0.85. Cronbach alphas for the current study were 01.85 for token economy, 0.92 for differential attention, 0.86 for response cost, 0.93 for positive practice, 0.92 for time-out, 0.92 for spanking, and 0.94 for medication. A score of 27 is the cutoff for “moderate” acceptance of a treatment procedure. Acculturation Rating Scale for Mexican Americans–II. (ARSMA-II; Cuellar, Arnold, & Maldonado, 1995). The ARSMA-II is an acculturation scale that measures cultural orientation toward Mexican culture and American culture independently. The 30-item ARSMA-II consists of two subscales: the 17-item Mexican Orientation Subscale (MOS; “I speak Spanish,” “My thinking is done in the Spanish language”) and the 13-item Anglo Orientation Subscale (AOS; “I like to identify myself as American,” “My friends while I was growing up were of Anglo origin”). All items are answered using a 5-item Likert-type scale with response choices ranging from “not at all” to “almost always/ extremely often.” The two subscales, the MOS and the AOS, are based on a multidimensional approach to acculturation (integrated, separated, assimilated, and marginalized). The ARSMA-II has been shown to have good reliability (Cronbach’s α = 0.86 and 0.88 for AOS and MOS, respectively) and validity (Pearson correlation coefficient r = 0.89 with the original scale). Items for each subscale (AOS and MOS) are added and divided by the number of items on each subscale separately to obtain the raw scores. Total Acculturation Score (ACC) is calculated by subtracting the MOS score from the AOS score (i.e., ACC = OS–MOS). This acculturation score is a linear measure of acculturation and is represented by positive scores for individuals who are more Anglo-oriented and negative scores for those who are more Mexican-oriented. The five different levels of acculturation based on this linear conceptualization of acculturation are determined by the following: Level I (<–1.33), Level II (≥–1.33 and ≤–0.07), Level III (>–0.07 and <1.19), Level IV (≥ 1.19 and < 2.45), and Level V (> 2.45) (Cuellar et al., 1995). Given the nature of the hypothesis concerning acculturation to AngloAmerican culture, the linear conceptualization of
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ARSMA-II scores was decided to be the best option for statistical analyses. Cronbach alphas for the current study were .83 for the MOS subscale, and .77 for the AOS subscale. Vignettes and treatment option scenarios. The vignette depicted a male (Javier) or female (Ana) child with externalizing behavior problems meeting diagnostic criteria for oppositional defiant disorder (ODD). Some of the specific behavior problems were refusing to pick up toys, throwing temper tantrums, being argumentative, and being touchy and annoyed. The vignette was followed by seven treatment options (response cost [restriction of privileges], time-out, positive practice [over-correction], token economy [sticker chart], differential attention, spanking, and medication). The vignettes and treatment options (except for medication) were adapted from the Jones et al. (1998) study. The following is the male vignette that was used in the study followed by the treatment descriptions in alphabetical order: Javier disobeys his mother a lot. He often refuses to do things his mother asks him to do, such as picking up his toys or doing other chores. When his mother asks him to put away his toys, Javier often has a temper tantrum which includes yelling and throwing his toys. If anything breaks during a temper tantrum, he sometimes swears and he blames his mother. He argues with his mother a lot, especially when he doesn’t get his own way. Javier also does things all the time to bother his younger sister, such as poking her over and over to make her cry. Javier also does things to his sister to make his mother mad. For example, the other day when his mother asked him to pour his sister’s juice, Javier poured it on his sister. Every time Javier’s mother tries to talk to him about getting along with his sister, Javier acts touchy and annoyed.
Treatment Options Scenarios differential attention To manage Javier’s behavior, his mother ignores him when he disobeys, and gives Javier lots of attention and praise every time Javier obeys. To ignore Javier, his mother doesn’t say anything to him and acts like she doesn’t notice him. Whenever Javier does what his mother tells him to do, his mother tells him how much she likes it, such as, “You did a good job of minding! Thank you for helping me”. medication To manage Javier’s behavior, his mother gives him medication that was prescribed by Javier’s doctor. The doctor told Javier’s mother that the medication
will help decrease his behavior problems. The medication was given in the form of a tablet.
positive practice To manage Javier’s behavior, his mother has him practice following directions whenever he does not obey. As an example, if Javier refuses to put his clothes in the hamper when told, his mother has Javier practice obeying by having him put 5 articles of clothing in the hamper, 1 at a time. If needed, Javier’s mother helps him practice by leading Javier to the hamper. positive reinforcement To manage Javier’s behavior, his mother waits until after Javier disobeys; a while later she again asks him to do the same or a different chore. Every time he obeys, his mother puts a sticker on Javier’s sticker chart. When Javier earns five stars, his mother lets him have extra time with things that he likes. The special things may be his favorite toy, riding his bike, playing outside with his friends, or playing on the swing. response cost To manage Javier’s behavior, whenever Javier disobeys his mother takes away a privilege. Javier’s mother tells Javier why he is losing the privilege for that day. The privileges that Javier might lose are things that he really likes, like a favorite cartoon, a bedtime story, or playing with a favorite toy. spanking To manage Javier’s behavior, his mother spanks him whenever he does not obey. As an example, if Javier refuses to put his shirt in the hamper, his mother walks Javier over to a chair and tells him that because he didn’t do what he was told, he is going to get a spanking. His mother then puts Javier over her lap and gives him two spanks on the bottom with the fingers of her hand. time-out To manage Javier’s behavior, his mother has him sit in a chair in the corner whenever he does not obey. His mother has him sit on the chair for 3 minutes. After 3 minutes, Javier’s mother will give him permission to get off the chair if he is quiet. If Javier gets off the chair before his mother gives permission, Javier must stay on the chair another 3 minutes. Procedures. Participants were recruited from the community through Hispanic-oriented events (e.g., Back to School Fiesta). Parents approached an information booth and were given information regarding the study such as the age group being targeted, time involved to complete the study, and
treatment acceptability among mexican american parents compensation for completing the study. The study was conducted at the local university in the department of psychology. Spanish and English forms were made available to all parents. Once parents provided consent, they were randomly assigned to either the male or female vignette in which a child displayed socially disruptive behavior problems. Parents were instructed to read the child vignette assigned to them. After reading the assigned vignette, parents were instructed to read seven different treatment option scenarios and asked to rate the acceptability of each treatment option. Detailed descriptions of each treatment option were provided. The treatment options were counterbalanced to control for order effect. It took parents approximately 30 minutes to complete the study. All parents who started the study were able to complete the study and were given $10 for their participation.
Results A 7 × 2 × 2 (Treatment Type × Parent Gender × Child Gender) repeated measures, multifactorial ANOVA was conducted to test the first hypothesis of the study. Annual income was entered as a covariate to control for any effects it might have on treatment acceptability. The multifactorial ANOVA revealed significant differences between treatments, F(6, 534) = 9.10, p < 0.05, partial η 2 = 0.093, and a significant interaction between treatment type and parent gender, F(6, 534) = 3.89, p < 0.05, partial η2 = 0.042. There was not a significant interaction between parent gender, child gender, and treatment type (F = 0.33, ns). Therefore, although there were
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significant differences between mothers’ and fathers’ acceptance of different treatments, the gender of the child did not interact with parent gender. The covariate of annual income did not have a significant influence on these results, F(6, 534) = 0.78, ns. Tukey’s Honestly Significant Difference test was used to determine which treatment techniques were preferred over others. Overall, Mexican American parents rated response cost significantly higher than any other treatment (Tukey’s ð = 2.998, p < 0.05). Following response cost, the treatment options of time-out, positive practice, and token economy were rated significantly higher than differential attention, spanking, and medication, but were not significantly different from one another. Similarly, differential attention and spanking were rated significantly higher than medication, although they were not significantly different from each other. Medication was rated least acceptable (please see Fig. 1). To determine what gender differences contributed to the significant interaction, one-way ANOVAs were used to compare mothers’ and fathers’ acceptability ratings for each treatment. Mothers rated token economy significantly higher than fathers, F(1, 94) = 10.86, p < 0.05, partial η2 = 0.104, whereas fathers rated spanking significantly higher than mothers, F(1, 94) = 5.94, p < 0.05, partial η2 = 0.059. Parents did not significantly differ on any other treatment (please see Table 2 for means and standard deviations of all treatments by parent gender). It should be noted that an a priori power analysis indicated that group sizes of
FIGURE 1.
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65 to 70 would be necessary to detect a medium effect size; our relatively small sample of fathers therefore decreased our power to detect an effect in these analyses. Prior to assessing the association between parents’ acculturation and treatment acceptability, the ranges, means, and standard deviations of these scales were determined (see Table 3). When assessing the association between acculturation and treatment acceptability, simple linear regressions were used. For each analysis, annual income level and ARSMA-II Total Acculturation scores were entered as the independent variables, with each of the seven treatments entered separately as dependent variables. Acculturation was not significantly related to the acceptability of any treatment (response cost r = 0.09, ns; time-out r = 0.10, ns; positive practice r = – 0.02, ns; token economy r = 0.16, ns; differential attention r = 0.04, ns; spanking r = 0.03, ns; and medication r = –0.05, ns), even after controlling for annual income. Post hoc power analyses revealed that with the 93 valid acculturation scores entered into the regression, the power to detect a moderate effect size was approximately 0.90 with α = 0.05 (ρ = 0.4; Cohen, 1977). Thus, nonsignificant results for this hypothesis appear to be valid. Given these results, it was decided to assess fathers’ and mothers’ acculturation separately to examine how each was associated with treatment acceptability. Higher acculturation scores for Mexican American fathers were significantly associated with increased acceptance of token economy (r = 0.33, p < 0.05, ES = 0.11). Thus, Mexican American fathers who were more acculturated to AngloAmerican culture were more likely to accept the use Table 2 Treatment acceptability ratings: Means (SDs) ranked by parent gender Parent gender: treatment options
Female Mean (SD)
Treatment options
Male Mean (SD)
Response cost
35.45 (5.29)
33.33 (6.21)
Time-out Token economy
30.82 (8.03) 30.14 (6.16)
Positive practice Differential attention Spanking
29.94 (8.40) 25.00 (8.09)
Medication
20.05 (9.66)
Response cost Time out Positive practice Spanking Token economy Differential attention Medication
22.44 (8.35)
31.56 (6.96) 27.39 (7.33) 26.80 (8.32) 25.62 (7.11) 24.20 (8.37) 19.09 (7.85)
Note. Significant difference in treatment acceptability between mothers and fathers for token economy and spanking, both ps < .05.
Table 3 Descriptive statistics for treatment acceptability and acculturation scales Scale
Min.
Max.
Mean (SD)
45 45 45 45 45 45 45
28.64 (6.82) 24.86 (8.22) 34.72 (5.68) 29.07 (8.10) 31.07 (7.65) 23.94 (8.55) 19.72 (9.05)
a
Treatment acceptability (TEI–SF) Token economy 11 Differential attention 11 Response cost 13 Positive practice 10 Time out 9 Spanking 9 Medication 9 Acculturation b MOS 1.88 AOS 2.46 ACC – 1.48
4.71 4.85 2.96
3.23 (0.57) 3.86 (0.45) 0.64 (0.82)
a Treatment Evaluation Inventory–Short Form (TEI-SF) scores range from 9 to 45. b Total Acculturation (ACC) range: –4 to 4; Mexican Orientation Subscale (MOS) range: 1 to 5; Anglo Orientation Subscale (AOS) range: 1 to 5.
of a token economy when dealing with a child’s behavior problems. Acculturation to Anglo-American culture was not significantly associated with acceptability of the other treatments for fathers (response cost r = –0.08, ns; time-out r = 0.15, ns; positive practice r = – 0.13, ns; differential attention r = 0.07, ns; spanking r = –0.07, ns; and medication r = 0.03, ns) or any of the treatments for mothers (response cost r = 0.16, ns; time-out r = 0.09, ns; positive practice r = 0.01, ns; token economy r = 0.06, ns; differential attention r = 0.03, ns; spanking r = 0.10, ns; and medication r = – 0.09, ns), even after controlling for annual income. It is important to note that these nonsignificant results may be a consequence of insufficient power. Post hoc power analyses revealed that, with just 31 valid acculturation scores entered into the regression for fathers, the power to detect a moderate effect was approximately 0.56 with α = 0.05 (ρ = 0.4; Cohen, 1977). However, with 62 valid acculturation scores entered for mothers, power to detect a moderate effect was approximately 0.8 with α = 0.05 (ρ = 0.4; Cohen, 1977). Thus, significant results for fathers should be considered preliminary and subject to further validation with a larger sample whereas the nonsignificant results for mothers appear to be valid.
Discussion This study sought to contribute to the treatment acceptability literature by including an ethnic minority sample. The objective of this study was to compare the acceptability of different child management interventions (i.e., response cost, time-out, positive practice, token economy, differ-
treatment acceptability among mexican american parents ential attention, spanking, and medication) for socially disruptive behavior problems among Mexican American parents with children between the ages of 2 and 8 years. We were also interested in examining possible within-subgroup variability due to acculturation. Overall, Mexican American parents in this study viewed response cost, a punishment-based technique, as the most acceptable intervention for managing behavior problems. This finding seems to contradict some of the previous treatment acceptability research suggesting that parents find reinforcement-based techniques more acceptable (e.g., Jones et al., 1998). Time-out, positive practice, and token economy were also rated as being at least moderately acceptable. Although these interventions likely require a substantial amount of time and effort from parents, they were still rated as acceptable by Mexican American parents. Mexican American parents viewed differential attention, spanking, and medication as less acceptable treatment options. An important aspect of this study was assessing for acculturation. Surprisingly, the results of this study indicate that acculturation changes had little impact on treatment acceptability ratings. Differences in acceptability ratings were observed only for Mexican American fathers in that more acculturated fathers demonstrated greater acceptance of token economy as a viable treatment option. Though this relationship was found, mothers still found token economy more acceptable than fathers and fathers found spanking more acceptable than mothers. Because of the small sample of fathers included in the study, caution should be raised when interpreting this finding. One unexpected finding was that Mexican American parents did not rate differential attention as a moderately acceptable intervention. Differential attention is commonly used as a behavioral technique for increasing positive child behaviors and decreasing negative behaviors. Differential attention consists of ignoring inappropriate negative attention-seeking behavior and positively reinforcing the child for engaging in a desired appropriate behavior. From the current study, it is not exactly known what parents were responding to regarding rating the acceptability of differential attention. Perhaps parents did not like the ignoring component involved in differential attention. It might also be that differential attention needs to be role-played or modeled with parents before they have a full understanding and appreciation for why and how differential attention is used. Caution is raised for clinicians who take this as evidence that using differential attention with Mexican Amer-
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icans is not appropriate. A more detailed analysis of the acceptability of differential attention is needed before making this type of clinical decision. As suggested in previous treatment acceptability research literature, knowledge and experience seems to influence treatment acceptability (Adams & Kelly, 1992; Hobbs, Walle, & Caldwell, 1984). Furthermore, Mexican American parents in this study viewed both differential attention and spankings as similarly acceptable. The findings of this study should be viewed in the context of several limitations. First, this was an analogue study that relied on use of hypothetical vignettes rather than real-life case examples. Though the vignettes appeared to have face validity regarding a child with externalizing behavior problems, it might be that these vignettes provided limited information and may not be representative of real-world situations. As previously stated, the vignettes used in the study were adapted from the Jones et al. (1998) study in which their vignettes described a child who met diagnostic criteria for oppositional defiant disorder (ODD). Other contextual factors that might approximate a real-world situation are asking parents what they have used before in trying to correct this problem. As the literature suggests, one predictor of treatment acceptability is if the parent has had previous experience with the technique (Adams & Kelly, 1992; Hobbs et al., 1984). Second, the parents who participated in this study were a community sample. Results may be different if a clinic sample of Mexican American parents who present for services to address their child’s socially disruptive behavior problems were included. As noted in the treatment acceptability literature, behavior problem severity influences treatment acceptability (Miller & Kelley, 1992). Given that a community sample was used, social desirability may have played a role in how parents responded. Parents may have wanted to be seen in a favorable light and thus rated spanking as a less acceptable treatment option. Third, due to the significant heterogeneity among Hispanic subgroups, results might lack generalizability to other Hispanic subgroups such as Puerto Ricans, Cubans, Argentineans, etc. Therefore, this study should be replicated to see if findings are consistent across Hispanic subgroups. Related to this, the findings may not generalize to a monolingual Spanish-speaking or limited English group of Mexican Americans, such as recent immigrants (i.e., less acculturated). Future studies should focus on Spanish-speaking parents such as recent immigrants who may not be as acculturated to American culture. Fourth, this study had a relatively small sample size. This was especially
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true for fathers in our sample. Future studies should include a larger sample of fathers and examine mother-father treatment acceptance differences within the same family. This might have some clinical implications if one parent is accepting of a treatment procedure prescribed by the therapist and the other parent does not agree. Fifth, given that parents were only exposed to one child vignette in the study, there is a potential stimulus sampling problem. Finally, a different methodology should be applied in assessing treatment acceptability. As an example, most of the studies to date, including the current study, used vignettes to assess treatment acceptability. These studies imply a certain level of knowledge and understanding regarding the technique that is discussed in the vignette. Perhaps a more ecologically valid approach would be to run parents through a hypothetical scenario in which various techniques are described and parents are asked to rate their acceptability. After this baseline, parents would then be given information about each technique (e.g., differential attention) and other relevant information such as the principles involved (e.g., ignoring an inappropriate behavior can lead to extinction), what skills are needed, and what tasks are involved in carrying out the technique (i.e., what the technique looks like). Along with this information, the technique can be presented to the parent via videotape, in vivo modeling with the parent, and/or role-playing. At the end of the demonstration, parents can be asked if they have any questions or comments about the technique being discussed. At the end, parents can be assessed again on the treatment acceptability of the technique that was just covered. This seems to approximate more of what occurs when parents are given relevant information about the techniques being used as part of an intervention. As an example, Parent-Child Interaction Therapy (PCIT; Eyberg et al., 1995; Hembree-Kigin & McNeil, 1995) uses a didactic component before each treatment phases (PCIT has two treatment phases: a relationship-enhancement phase and a discipline phase). During this didactic, each technique to be used during that specific phase is discussed in detail with parents. After a discussion that includes rationales for why the technique is being used and examples, the technique is modeled for the parent and role-played with the parent. In sum, findings from this study suggest that English-speaking Mexican American parents find response cost, a punishment-based technique, as the most acceptable child management strategy. Though there was a statistical significance between response cost and the other behavioral techniques (e.g., time-out, positive reinforcement, token economy, and differential attention), it should be noted
that parents still found time-out, token economy, and positive practice moderately acceptable. Given this, it seems that these techniques can be introduced as viable treatment options when working with Mexican American parents. Assessing for treatment acceptability with Mexican Americans and other ethnic minority groups might be one approach to developing and implementing culturally appropriate psychosocial interventions. References Adams, C., & Kelley, M. (1992). Managing sibling aggression: Overcorrection as an alternative to time out. Behavior Therapy, 23, 707–717. Alegria, M., Canino, G., Rios, R., Vera, M., Calderon, J., Rusch, D., & Ortega, A. (2002). Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino whites. Psychiatric Services, 53, 547–555. American Psychological Association (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377–402. Berry, J. W. (2003). Conceptual approaches to acculturation. In K. M. Chun, & P. B. Organista (Eds.), Acculturation: Advances in theory, measurement, and applied research (pp. 17–37). Washington, DC: American Psychological Association. Boothe, J., Borrego Jr., J., Hill, C., & Anhalt, K. (2005). Treatment acceptability and treatment compliance in ethnic minority populations. In C. L. Frisby, & C. Reynolds (Eds.), Comprehensive handbook of multicultural school psychology (pp. 945–972). New York: John Wiley and Sons. Buriel, R., Mercado, R., Rodriquez, J., & Chavez, J. M. (1991). Mexican American disciplinary practices and attitudes toward child maltreatment: A comparison of foreign- and native-born mothers. Hispanic Journal of Behavioral Sciences, 13, 78–94. Calzada, E. J., & Eyberg, S. M. (2002). Self-reported parenting practices in Dominican and Puerto Rican mothers of young children. Journal of Clinical Child and Adolescent Psychology, 42, 354–363. Cohen, J. (1977). Statistical power analysis for the behavioral sciences (Rev. ed.) New York: Academic Press. Cousins, J. H., Power, T. G., & Olvera-Ezzell, N. (1993). Mexican American mothers’ socialization strategies: Effects of education, acculturation, and health locus of control. Journal of Experimental Child Psychology, 55, 258–276. Cuellar, I., Arnold, B., & Maldonado, R. (1995). Acculturation rating scale for Mexican-Americans-II: A revision of the original ARSMA scale. Hispanic Journal of Behavioral Sciences, 17, 275–304. Delgado-Gaitan, D. (1993). Parenting in two generations of Mexican American families. International Journal of Behavioral Development, 16, 409–427. De Von Figueroa-Moseley, C., Ramey, C. T., Keltner, B., & Lanzi, R. G. (2006). Variations in Latino parenting practices and their effects on child cognitive developmental outcomes. Hispanic Journal of Behavioral Sciences, 28, 102–114. Elliott, S., Witt, J., Galvin, G., & Peterson, R. (1984). Acceptability of positive and reductive behavior interventions: Factors that influence teachers’ decisions. Journal of School Psychology, 22, 353–360. Eyberg, S. M., Boggs, S., & Algina, J. (1995). Parent-child
treatment acceptability among mexican american parents interaction therapy: A psychosocial model for the treatment of young children with conduct problem behavior and their families. Psychopharmacology Bulletin, 31, 83–91. Forehand, R., & Kotchick, B. A. (1996). Cultural diversity: A wake-up call for parent training. Behavior Therapy, 27, 187–206. Foster, S. L., & Mash, E. J. (1999). Assessing social validity in clinical treatment research: Issues and procedures. Journal of Consulting and Clinical Psychology, 67, 308–319. Gary, F. A. (2005). Stigma: Barriers to mental health care among ethnic minorities. Issues in Mental Health Nursing, 26, 979–999. Heffer, R., & Kelley, M. (1987). Mother’s acceptance of behavioral interventions for children: The influence of parent race and income. Behavior Therapy, 18, 153–163. Hembree-Kigin, T., & McNeil, C. B. (1995). Parent-child interaction therapy. New York: Plenum. Hill, N. E., Bush, K. R., & Roosa, M. W. (2003). Parenting and family socialization strategies and children’s mental health: Low-income Mexican American and Euro-American mothers and children. Child Development, 74, 189–204. Hobbs, S. A., Walle, D. L., & Caldwell, H. S. (1984). Maternal evaluation of social reinforcement and time out: Effects of brief parent training. Journal of Consulting and Clinical Psychology, 52, 135–136. Jones, M., Eyberg, S., Adams, C., & Boggs, S. (1998). Treatment acceptability of behavioral interventions for children: An assessment by mothers of children with disruptive behavior disorders. Child and Family Behavior Therapy, 20, 15–27. Kazdin, A. (1980). Acceptability of alternative treatment for deviant child behavior. Journal of Applied Behavior Analysis, 13, 259–273. Kazdin, A. (1981). Acceptability of child treatment techniques: The influence of treatment efficacy and adverse side effects. Behavior Therapy, 12, 493–506. Kelley, M., Heffer, R., Gresham, F., & Elliott, S. (1989). Development of a modified treatment evaluation inventory. Journal of Psychopathology and Behavioral Assessment, 11, 235–247. Kelley, M., Grace, N., & Elliott, S. (1990). Acceptability of positive and punitive discipline methods: Comparisons among abusive, potentially abusive, and nonabusive parents. Child Abuse and Neglect, 14, 219–226. Knight, G. P., Virdin, L. M., & Roosa, M. (1994). Socialization and family correlates of mental health outcomes among Hispanic and Anglo American children: Consideration of cross ethnic scalar equivalence. Child Development, 65, 212–224. Laosa, L. M. (1980). Maternal teaching strategies in Chicano and Anglo-American families: The influence of culture and education on maternal behavior. Child Development, 51, 759–765. McCabe, K., Yeh, M., Hough, R., Landsverk, J., Hurlburt, M., Culver, S., & Reynolds, B. (1999). Racial/ethnic representation across five public sectors of care for youth. Journal of Emotional and Behavioral Disorders, 7, 72–82. Medora, N. P., Wilson, S., & Larson, H. (2001). Attitudes towards parenting strategies, potential child abuse, and parental satisfaction of ethnically diverse low-income U.S. mothers. The Journal of Social Psychology, 141, 335–348. Miller, D., & Kelley, M. (1992). Treatment acceptability: The
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effects of parent gender, marital adjustment, and child behavior. Child and Family Behavior Therapy, 14, 11–23. Negy, C., & Woods, D. (1992). The importance of acculturation in understanding research with Hispanic-Americans. Hispanic Journal of Behavioral Sciences, 14, 224–247. Planos, R., Zayas, L., & Busch-Rossnagel, N. A. (1995). Acculturation and teaching behaviors of Dominican and Puerto Rican mothers. Hispanic Journal of Behavioral Sciences, 17, 225–236. Sabogal, F., Marin, G., Otero-Sabogal, R., Marin, B. V., & Perez-Stable, E. J. (1987). Hispanic familism and acculturation: What changes and what doesn’t? Hispanic Journal of Behavioral Sciences, 9, 397–412. Tarnowski, K. J., Simonian, S. J., Park, A., & Bekeny, P. (1992). Acceptability of treatments for child behavioral disturbance: Race, socioeconomic status, and multicomponent treatment effects. Child and Family Behavior Therapy, 14, 25–37. Trimble, J. E. (2003). Introduction: Social change and acculturation. In K. M. Chun, & P. B. Organista (Eds.), Acculturation: Advances in theory, measurement, and applied research (pp. 3–13). Washington, DC: American Psychological Association. U.S. Census Bureau. (2004). American community survey. Retrieved February 26, 2007, from http://www.census.gov/ acs/www/ U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity. A supplement to mental health: A report of the surgeon general. Rockville, MD: Author. Varela, R. E., Vernberg, E. M., Sanchez-Sosa, J. J., Riveros, A., Mitchell, M., & Mashunkashey, M. M. (2004). Parenting style of Mexican, Mexican American, and Caucasian NonHispanic families: Social context and cultural influences. Journal of Family Psychology, 18, 651–657. Vega, W. (1995). The study of Latino families: A point of departure. In R. E. Zambrana (Ed.), Understanding Latino families: Scholarship, policy, and practice (pp. 3–17). Thousand Oaks, CA: Sage Publications. Vega, W., & Alegria, M. (2001). Latino mental health and treatment in the United States. In M. Aguirre-Molina, C. W. Molina, & R. E. Zambrana (Eds.), Health issues in the Latino community (pp. 179–208). San Francisco: Jossey-Bass. Vega, W., Kolody, B., & Aguilar-Gaxiola, S. (2001). Help seeking for mental health problems among Mexican Americans. Journal of Immigrant Health, 3, 133–140. Wolf, M. (1978). Social validity: The case for subjective measurement. Journal of Applied Behavior Analysis, 11, 203–214. Yeh, M., McCabe, K., Hurlburt, M., Hough, R., Hazen, A., Culver, S., Garland, A., & Landsverk, J. (2002). Referral sources, diagnoses, and service types of youth in public outpatient mental health care: A focus on ethnic minorities. Journal of Behavioral Health Services and Research, 29, 45–60. Zayas, L. (1992). Social distress and families in crisis: A multicultural perspective. Journal of Social Distress and the Homeless, 1, 291–309. Zayas, L. H., & Solari, F. (1994). Early childhood socialization in Hispanic families: Context, culture, and practice implications. Professional Psychology: Research and Practice, 25, 200–206. R E C E I V E D : December 12, 2005 A C C E P T E D : August 28, 2006 Available online 29 June 2007
Treatment Acceptability Among Mexican American Parents Joaquin Borrego, Elizabeth S. Ibanez, Stuart J. Spendlove, Joy R. Pemberton Texas Tech University
There is a void in the literature with regard to Hispanic parents’ views about common interventions for children with behavior problems. The purpose of this study was to examine the treatment acceptability of child management techniques in a Mexican American sample. Parents’ acculturation was also examined to determine if it would account for differences in treatment acceptability. Mexican American parents found response cost, a punishment-based technique, more acceptable than positive reinforcement– based techniques (e.g., differential attention). Results suggest that Mexican American parents’ acculturation has little impact on acceptability of child management interventions. No association was found between mothers’ acculturation and treatment acceptability. However, more acculturated Mexican American fathers viewed token economy as more acceptable than less acculturated fathers. Results are discussed in the context of clinical work and research with Mexican Americans.
H I S PA N I C S R E C E N T LY S U R PA S S E D A F R I C A N A M E R I C A N S as the largest ethnic minority group in the United States (U.S. Census Bureau, 2004). Despite this significant population increase, there continues to be a paucity of research related to mental health service delivery with Hispanics. This is crucial because research has consistently found that Hispanics tend to underutilize mental health services (U.S. We would like to thank Meghan M. Goodrich for feedback and editorial suggestions regarding the manuscript. This research was supported in part by a grant, College of Arts and Sciences, Texas Tech University. Portions of this research were presented at the 38th Annual Meeting of the Association for Advancement of Behavior Therapy, New Orleans, Louisiana. Address correspondence to Joaquin Borrego, Department of Psychology, Texas Tech University, Lubbock, TX 79409-2051, USA; e-mail: [email protected]. 0005-7894/07/0218–0227$1.00/0 © 2007 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.
DHHS, 2001; Yeh et al., 2002), receive lesser quality mental health services (U.S. DHHS, 2001), and are generally dissatisfied with the quality of the services received (Alegria et al., 2002). Given this, it appears that the mental health system is not adequately prepared to meet the needs of Hispanics (McCabe et al., 1999). Though stigma of mental health services does seem to influence utilization patterns (Gary, 2005), Hispanics do utilize formal mental health services. When utilizing services, U.S.-born Mexican Americans are likely to seek services from either physicians or counselors (Vega, Kolody, & AguilarGaxiola, 2001). Research also suggests that relying on family and other social networks does not serve as a substitute for seeking formal mental health services (Vega & Alegria, 2001). Given the disparities in mental health care, it is paramount that clinical researchers continue to develop or adapt, implement, and evaluate mental health interventions that meet the psychosocial needs of these families by providing services that are culturally appropriate (American Psychological Association, 2003). This is especially true for parenting programs that target culturally diverse families (Forehand & Kotchick, 1996). One strategy in developing and providing culturally appropriate mental health services is to address issues related to social validity. According to Wolf (1978), a socially valid intervention is one that has meaning and value to a specific community. Wolf felt that it was important to get a community’s input when designing, implementing, and evaluating an intervention. As he argued, a community may not like or agree with an intervention, even when it has been shown to be effective. A community can be flexibly defined, ranging from a local neighborhood facing a particular problem (e.g., high crime rate) to a group of people sharing similar characteristics (e.g., Mexican American parents). Social validity can be evaluated at three levels: (a) the social significance of the goals (i.e., if clinicians were to identify
treatment acceptability among mexican american parents treatment goals, would Mexican American parents agree on the same treatment goals?); (b) the social appropriateness of the procedures implemented (i.e., would Mexican American parents consider a specific treatment acceptable?); and (c) the social importance of the effects (i.e., are Mexican American parents satisfied with the outcome?). Given this, examining social validity is relevant in the context of conducting and evaluating treatment research (Foster & Mash, 1999). The current study focuses on the second aspect of social validity: acceptability of treatment procedures. Treatment acceptability is defined in terms of the judgments made by potential consumers of a treatment about the appropriateness, fairness, reasonableness, and nonintrusiveness of treatment procedures (Kazdin, 1981). Providing acceptable treatments is important because it can lead to increased cooperation, compliance, and effectiveness of the intervention (Kazdin, 1980). Treatment factors such as efficacy (Adams & Kelley, 1992), intervention type (Heffer & Kelley, 1987), complexity or time to implement (Elliott, Witt, Galvin, & Peterson, 1984), and side effects (Kazdin, 1981) have been found to influence treatment acceptability judgments. However, treatment efficacy alone does not predict acceptability or effectiveness with diverse populations (Boothe, Borrego, Hill, & Anhalt, 2005). Additionally, client factors that influence treatment acceptability include the severity of behavior problems (Kazdin, 1981), marital distress (Miller & Kelley, 1992), and socioeconomic status (Kelley, Grace, & Elliott, 1990). Generally, the treatment acceptability literature has shown that reinforcement-based treatments are rated higher than punishment-based treatments. In other words, treatments focused on increasing prosocial behaviors (e.g., positive reinforcement for sharing) are rated higher than interventions that focus on decreasing negative behaviors (e.g., timeout for whining). As an example, Jones, Eyberg, Adams, and Boggs (1998) examined treatment acceptability in a clinic sample and found that mothers of children referred for services for socially disruptive behavior problems preferred reinforcement the most and spanking the least. Very few studies, however, have examined treatment acceptability with racial/ethnic minority populations. When comparing African American and Caucasian mothers from either low or middleupper income levels, Heffer and Kelley (1987) found that, regardless of race and income, mothers viewed response cost and positive reinforcement as acceptable child management strategies, but low-income mothers rated time-out significantly lower than
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middle-upper income mothers. The authors conducted further analyses to determine the degree to which mothers rated a treatment as moderately acceptable. The results suggest that fewer lowincome African American mothers were accepting of time-out than middle-upper income Caucasian and African American mothers. In addition, fewer middle-upper income Caucasian mothers were accepting of spanking than low-income Caucasian mothers, and low-income and middle-upper income African American mothers. Similar percentages of low and middle-upper income African American mothers rated spanking as acceptable. The Heffer and Kelly findings suggest that income levels and possibly race influence treatment acceptability ratings. Tarnowski, Simonian, Park, and Bekeny (1992) found that treatment acceptability ratings did not vary as a function of socioeconomic status between African American and Caucasian mothers. The authors did not find race to significantly affect treatment acceptability ratings. Unfortunately, the two studies cannot be compared due to assessment and operationalization differences. In summary, though there are numerous treatment acceptability studies, very few have focused on racial and ethnic minority populations. Of the few studies available, the focus has been on African Americans (e.g., Heffer & Kelly, 1987; Tarnowski et al., 1992). To date, no studies have examined treatment acceptability with Hispanics. Thus, it is not known what child management strategies Hispanic parents would find acceptable. There may be treatment acceptability differences that can influence different aspects of treatment (e.g., following through with treatment recommendations). As has been suggested, this is important to examine because culture and socialization play an important role in shaping parenting practices (Zayas & Solari, 1994). Because the term Hispanic is used as an umbrella term to encompass numerous subgroups, it would be erroneous to assume that this group is homogeneous. Hispanics, as a whole, are a very heterogeneous group comprised of different subgroups (e.g., Mexicans, Cubans, Puerto Ricans, Central and South Americans). Of the approximately 40 million Hispanics residing in the U.S., Mexican Americans comprise the largest subgroup at 64% (U.S. Census Bureau, 2004). There are significant Hispanic subgroup differences with regard to immigration patterns, customs, socioeconomic status, region settlement, language, and other cultural characteristics (De Von FigueroaMoseley, Ramey, Keltner, and Lanzi, 2006; Vega, 1995). As an example, there is recent research to suggest that Hispanic subgroups differ along different parenting dimensions (e.g., De Von
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Figueroa-Moseley et al. 2006; Planos, Zayas, & Busch-Rossnagel, 1995). In addition to subgroup differences, there may also be important within-subgroup differences. The construct of acculturation has received much attention as a means of trying to account for Hispanic within-group differences (Negy and Woods, 1992). Acculturation is a multidimensional sociocultural process whereby an individual experiences changes to varying degrees across different domains (Berry, 2003). Through coming in contact with the dominant culture, social and environmental processes shape various attitudes, beliefs, values, and behaviors. Acculturation includes changes at both the individual (psychological) and group (sociocultural) levels (Trimble, 2003). The assumption behind the acculturative process is that highly acculturated Hispanics (whether bicultural or assimilated) start adopting attitudes, values, and behaviors similar to Caucasians. Acculturation has been found to influence different processes, such as the cultural value of familism (Sabogal, Marin, Otero-Sabogal, Marin, & Perez-Stable, 1987), childrearing (Delgado-Gaitan, 1993), socialization of children (Cousins, Power, & Olvera-Ezzell, 1993), and discipline strategies (Buriel, Mercado, Rodriquez, & Chavez, 1991). Unfortunately, there is no conclusive parenting (e.g., discipline) research on Hispanics on which to draw valid comparisons with Caucasians (Calzada and Eyberg, 2002). This might be due in part to the disagreement about the consistency of parenting styles and practices in Hispanic families (Hill, Bush, & Roosa, 2003). Not surprisingly, there are mixed findings with regard to Hispanic parenting practices in the literature. A good illustration is the differences found in parenting styles. Some studies have found that Hispanic parents are authoritarian (e.g., Zayas, 1992), while other studies have found that Hispanic parents report being more authoritative than authoritarian (Varela et al., 2004). There is also literature available regarding the use of more specific child management strategies by Hispanic parents. A study by Medora, Wilson, and Larson (2001) found similar parenting strategies between Caucasian, Hispanic, and African American mothers. Medora and colleagues found that all mothers listed spanking as the least preferable parenting strategy, whereas praise, reasoning, and differential attention were listed as highly preferable. This study was supported by Calzada and Eyberg (2002), who found that Hispanic mothers use high levels of praise and physical affection. Contrary to these studies, other research has found that Hispanic parents use physical discipline as a means of managing their child’s behavior and rely
less on praising their child (Knight, Virdin, & Roosa, 1994; Laosa, 1980). Research with Mexican-origin parents has found that child management strategies of native and foreign-born Mexican mothers differ depending on acculturation (Buriel et al., 1991). After controlling for socioeconomic status, Mexican American mothers preferred nonphysical discipline, whereas foreign-born Mexican mothers were more likely to endorse using spanking (Buriel et al.). As highlighted by this literature, no consistent pattern emerges with regard to Hispanic parenting. However, acculturation may be an important construct to consider when conducting research with Hispanics because of the potential within-subgroup variability that may exist. Including variables such as acculturation and specifying subgroups of Hispanic populations (e.g., Mexican Americans) may assist with interpreting some of the mixed findings in the literature. In treatment acceptability research with Hispanics, it may be necessary to assess acculturation as it may affect the degree to which parents find different treatments acceptable.
Purpose The purpose of this study was to assess treatment acceptability of common child management techniques among Mexican American parents and to examine whether acculturation has an impact on acceptability of different treatment strategies. We were interested in examining whether previous findings, that reinforcement-based techniques are generally more acceptable (Jones et al., 1998), would generalize to a Mexican American sample. The hypotheses were also based on previous research findings (e.g., Calzada & Eyberg, 2002; Medora et al., 2001) that Hispanics preferred and used positive reinforcement (e.g., praise) strategies. Given this, the following hypotheses were made: 1. Overall, reinforcement-based techniques (e.g., token economy and differential attention) would be rated as more acceptable than punishment-based techniques (e.g., response cost, spanking, and time-out) and medication. 2. As Mexican American parents increased in acculturation to Anglo-American culture, reinforcement-based techniques would be rated as more acceptable than punishment-based techniques and medication.
Method participants Participants consisted of a west Texas community sample of 97 Mexican American parents with
treatment acceptability among mexican american parents children between 2 and 8 years old. People of Mexican origin account for approximately 33% of the population in this midsize west Texas community. There were 63 mothers and 34 fathers. Mothers and fathers were from different families. Parents’ mean age was 33 years (SD = 8.22). Seventy-two percent of parents were married, 10% divorced, and 18% single/never been married. Parents’ education level was as follows: 34.4% had a high school degree and 32.3% had some college. Thirty-one percent of participants reported annual household incomes of less than or equal to $15,000. Please see Table 1 for detailed demographic information.
materials The following materials were available in Spanish and English but all 97 participants chose English versions. Demographics questionnaire. Demographic variables included the parent’s age, gender, income, marital status, education level, and ethnicity.
Table 1 Demographic Information
Gender of parent Male Female Parent’s marital status Single/never married Married Divorced Number of children 1 2 3 4+ Parent's education level Jr. high Some high school High school degree or GED Some college College degree Graduate degree Annual household income <15,000 15,000–25,000 25,001–50,000 >50,001 Missing Generation status 1st Generation 2nd Generation 3rd Generation 4th Generation 5th Generation
N
%
33 63
34.4 65.6
16 70 10
16.7 72.9 10.4
16 39 23 18
16.7 40.6 24.0 18.8
7 12 33 31 9 4
7.3 12.5 34.4 32.3 9.4 4.2
30 23 30 9 4
31.2 24.0 31.3 9.4 4.2
8 18 22 33 15
8.3 18.8 22.9 34.4 15.6
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Treatment evaluation inventory–short form. (TEI-SF; Kelley, Heffer, Gresham, & Elliott, 1989). The TEI-SF is a 9-question, 5-point Likert rating scale, ranging from “strongly disagree” to “strongly agree,” which is completed for each treatment alternative. Scores for each treatment option can range from a minimum of 9 to a maximum of 45. Kelley et al. (1989) found that the TEI-SF is an internally consistent and valid measure. The coefficient alpha was reported to be 0.85. Cronbach alphas for the current study were 01.85 for token economy, 0.92 for differential attention, 0.86 for response cost, 0.93 for positive practice, 0.92 for time-out, 0.92 for spanking, and 0.94 for medication. A score of 27 is the cutoff for “moderate” acceptance of a treatment procedure. Acculturation Rating Scale for Mexican Americans–II. (ARSMA-II; Cuellar, Arnold, & Maldonado, 1995). The ARSMA-II is an acculturation scale that measures cultural orientation toward Mexican culture and American culture independently. The 30-item ARSMA-II consists of two subscales: the 17-item Mexican Orientation Subscale (MOS; “I speak Spanish,” “My thinking is done in the Spanish language”) and the 13-item Anglo Orientation Subscale (AOS; “I like to identify myself as American,” “My friends while I was growing up were of Anglo origin”). All items are answered using a 5-item Likert-type scale with response choices ranging from “not at all” to “almost always/ extremely often.” The two subscales, the MOS and the AOS, are based on a multidimensional approach to acculturation (integrated, separated, assimilated, and marginalized). The ARSMA-II has been shown to have good reliability (Cronbach’s α = 0.86 and 0.88 for AOS and MOS, respectively) and validity (Pearson correlation coefficient r = 0.89 with the original scale). Items for each subscale (AOS and MOS) are added and divided by the number of items on each subscale separately to obtain the raw scores. Total Acculturation Score (ACC) is calculated by subtracting the MOS score from the AOS score (i.e., ACC = OS–MOS). This acculturation score is a linear measure of acculturation and is represented by positive scores for individuals who are more Anglo-oriented and negative scores for those who are more Mexican-oriented. The five different levels of acculturation based on this linear conceptualization of acculturation are determined by the following: Level I (<–1.33), Level II (≥–1.33 and ≤–0.07), Level III (>–0.07 and <1.19), Level IV (≥ 1.19 and < 2.45), and Level V (> 2.45) (Cuellar et al., 1995). Given the nature of the hypothesis concerning acculturation to AngloAmerican culture, the linear conceptualization of
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ARSMA-II scores was decided to be the best option for statistical analyses. Cronbach alphas for the current study were .83 for the MOS subscale, and .77 for the AOS subscale. Vignettes and treatment option scenarios. The vignette depicted a male (Javier) or female (Ana) child with externalizing behavior problems meeting diagnostic criteria for oppositional defiant disorder (ODD). Some of the specific behavior problems were refusing to pick up toys, throwing temper tantrums, being argumentative, and being touchy and annoyed. The vignette was followed by seven treatment options (response cost [restriction of privileges], time-out, positive practice [over-correction], token economy [sticker chart], differential attention, spanking, and medication). The vignettes and treatment options (except for medication) were adapted from the Jones et al. (1998) study. The following is the male vignette that was used in the study followed by the treatment descriptions in alphabetical order: Javier disobeys his mother a lot. He often refuses to do things his mother asks him to do, such as picking up his toys or doing other chores. When his mother asks him to put away his toys, Javier often has a temper tantrum which includes yelling and throwing his toys. If anything breaks during a temper tantrum, he sometimes swears and he blames his mother. He argues with his mother a lot, especially when he doesn’t get his own way. Javier also does things all the time to bother his younger sister, such as poking her over and over to make her cry. Javier also does things to his sister to make his mother mad. For example, the other day when his mother asked him to pour his sister’s juice, Javier poured it on his sister. Every time Javier’s mother tries to talk to him about getting along with his sister, Javier acts touchy and annoyed.
Treatment Options Scenarios differential attention To manage Javier’s behavior, his mother ignores him when he disobeys, and gives Javier lots of attention and praise every time Javier obeys. To ignore Javier, his mother doesn’t say anything to him and acts like she doesn’t notice him. Whenever Javier does what his mother tells him to do, his mother tells him how much she likes it, such as, “You did a good job of minding! Thank you for helping me”. medication To manage Javier’s behavior, his mother gives him medication that was prescribed by Javier’s doctor. The doctor told Javier’s mother that the medication
will help decrease his behavior problems. The medication was given in the form of a tablet.
positive practice To manage Javier’s behavior, his mother has him practice following directions whenever he does not obey. As an example, if Javier refuses to put his clothes in the hamper when told, his mother has Javier practice obeying by having him put 5 articles of clothing in the hamper, 1 at a time. If needed, Javier’s mother helps him practice by leading Javier to the hamper. positive reinforcement To manage Javier’s behavior, his mother waits until after Javier disobeys; a while later she again asks him to do the same or a different chore. Every time he obeys, his mother puts a sticker on Javier’s sticker chart. When Javier earns five stars, his mother lets him have extra time with things that he likes. The special things may be his favorite toy, riding his bike, playing outside with his friends, or playing on the swing. response cost To manage Javier’s behavior, whenever Javier disobeys his mother takes away a privilege. Javier’s mother tells Javier why he is losing the privilege for that day. The privileges that Javier might lose are things that he really likes, like a favorite cartoon, a bedtime story, or playing with a favorite toy. spanking To manage Javier’s behavior, his mother spanks him whenever he does not obey. As an example, if Javier refuses to put his shirt in the hamper, his mother walks Javier over to a chair and tells him that because he didn’t do what he was told, he is going to get a spanking. His mother then puts Javier over her lap and gives him two spanks on the bottom with the fingers of her hand. time-out To manage Javier’s behavior, his mother has him sit in a chair in the corner whenever he does not obey. His mother has him sit on the chair for 3 minutes. After 3 minutes, Javier’s mother will give him permission to get off the chair if he is quiet. If Javier gets off the chair before his mother gives permission, Javier must stay on the chair another 3 minutes. Procedures. Participants were recruited from the community through Hispanic-oriented events (e.g., Back to School Fiesta). Parents approached an information booth and were given information regarding the study such as the age group being targeted, time involved to complete the study, and
treatment acceptability among mexican american parents compensation for completing the study. The study was conducted at the local university in the department of psychology. Spanish and English forms were made available to all parents. Once parents provided consent, they were randomly assigned to either the male or female vignette in which a child displayed socially disruptive behavior problems. Parents were instructed to read the child vignette assigned to them. After reading the assigned vignette, parents were instructed to read seven different treatment option scenarios and asked to rate the acceptability of each treatment option. Detailed descriptions of each treatment option were provided. The treatment options were counterbalanced to control for order effect. It took parents approximately 30 minutes to complete the study. All parents who started the study were able to complete the study and were given $10 for their participation.
Results A 7 × 2 × 2 (Treatment Type × Parent Gender × Child Gender) repeated measures, multifactorial ANOVA was conducted to test the first hypothesis of the study. Annual income was entered as a covariate to control for any effects it might have on treatment acceptability. The multifactorial ANOVA revealed significant differences between treatments, F(6, 534) = 9.10, p < 0.05, partial η 2 = 0.093, and a significant interaction between treatment type and parent gender, F(6, 534) = 3.89, p < 0.05, partial η2 = 0.042. There was not a significant interaction between parent gender, child gender, and treatment type (F = 0.33, ns). Therefore, although there were
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significant differences between mothers’ and fathers’ acceptance of different treatments, the gender of the child did not interact with parent gender. The covariate of annual income did not have a significant influence on these results, F(6, 534) = 0.78, ns. Tukey’s Honestly Significant Difference test was used to determine which treatment techniques were preferred over others. Overall, Mexican American parents rated response cost significantly higher than any other treatment (Tukey’s ð = 2.998, p < 0.05). Following response cost, the treatment options of time-out, positive practice, and token economy were rated significantly higher than differential attention, spanking, and medication, but were not significantly different from one another. Similarly, differential attention and spanking were rated significantly higher than medication, although they were not significantly different from each other. Medication was rated least acceptable (please see Fig. 1). To determine what gender differences contributed to the significant interaction, one-way ANOVAs were used to compare mothers’ and fathers’ acceptability ratings for each treatment. Mothers rated token economy significantly higher than fathers, F(1, 94) = 10.86, p < 0.05, partial η2 = 0.104, whereas fathers rated spanking significantly higher than mothers, F(1, 94) = 5.94, p < 0.05, partial η2 = 0.059. Parents did not significantly differ on any other treatment (please see Table 2 for means and standard deviations of all treatments by parent gender). It should be noted that an a priori power analysis indicated that group sizes of
FIGURE 1.
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65 to 70 would be necessary to detect a medium effect size; our relatively small sample of fathers therefore decreased our power to detect an effect in these analyses. Prior to assessing the association between parents’ acculturation and treatment acceptability, the ranges, means, and standard deviations of these scales were determined (see Table 3). When assessing the association between acculturation and treatment acceptability, simple linear regressions were used. For each analysis, annual income level and ARSMA-II Total Acculturation scores were entered as the independent variables, with each of the seven treatments entered separately as dependent variables. Acculturation was not significantly related to the acceptability of any treatment (response cost r = 0.09, ns; time-out r = 0.10, ns; positive practice r = – 0.02, ns; token economy r = 0.16, ns; differential attention r = 0.04, ns; spanking r = 0.03, ns; and medication r = –0.05, ns), even after controlling for annual income. Post hoc power analyses revealed that with the 93 valid acculturation scores entered into the regression, the power to detect a moderate effect size was approximately 0.90 with α = 0.05 (ρ = 0.4; Cohen, 1977). Thus, nonsignificant results for this hypothesis appear to be valid. Given these results, it was decided to assess fathers’ and mothers’ acculturation separately to examine how each was associated with treatment acceptability. Higher acculturation scores for Mexican American fathers were significantly associated with increased acceptance of token economy (r = 0.33, p < 0.05, ES = 0.11). Thus, Mexican American fathers who were more acculturated to AngloAmerican culture were more likely to accept the use Table 2 Treatment acceptability ratings: Means (SDs) ranked by parent gender Parent gender: treatment options
Female Mean (SD)
Treatment options
Male Mean (SD)
Response cost
35.45 (5.29)
33.33 (6.21)
Time-out Token economy
30.82 (8.03) 30.14 (6.16)
Positive practice Differential attention Spanking
29.94 (8.40) 25.00 (8.09)
Medication
20.05 (9.66)
Response cost Time out Positive practice Spanking Token economy Differential attention Medication
22.44 (8.35)
31.56 (6.96) 27.39 (7.33) 26.80 (8.32) 25.62 (7.11) 24.20 (8.37) 19.09 (7.85)
Note. Significant difference in treatment acceptability between mothers and fathers for token economy and spanking, both ps < .05.
Table 3 Descriptive statistics for treatment acceptability and acculturation scales Scale
Min.
Max.
Mean (SD)
45 45 45 45 45 45 45
28.64 (6.82) 24.86 (8.22) 34.72 (5.68) 29.07 (8.10) 31.07 (7.65) 23.94 (8.55) 19.72 (9.05)
a
Treatment acceptability (TEI–SF) Token economy 11 Differential attention 11 Response cost 13 Positive practice 10 Time out 9 Spanking 9 Medication 9 Acculturation b MOS 1.88 AOS 2.46 ACC – 1.48
4.71 4.85 2.96
3.23 (0.57) 3.86 (0.45) 0.64 (0.82)
a Treatment Evaluation Inventory–Short Form (TEI-SF) scores range from 9 to 45. b Total Acculturation (ACC) range: –4 to 4; Mexican Orientation Subscale (MOS) range: 1 to 5; Anglo Orientation Subscale (AOS) range: 1 to 5.
of a token economy when dealing with a child’s behavior problems. Acculturation to Anglo-American culture was not significantly associated with acceptability of the other treatments for fathers (response cost r = –0.08, ns; time-out r = 0.15, ns; positive practice r = – 0.13, ns; differential attention r = 0.07, ns; spanking r = –0.07, ns; and medication r = 0.03, ns) or any of the treatments for mothers (response cost r = 0.16, ns; time-out r = 0.09, ns; positive practice r = 0.01, ns; token economy r = 0.06, ns; differential attention r = 0.03, ns; spanking r = 0.10, ns; and medication r = – 0.09, ns), even after controlling for annual income. It is important to note that these nonsignificant results may be a consequence of insufficient power. Post hoc power analyses revealed that, with just 31 valid acculturation scores entered into the regression for fathers, the power to detect a moderate effect was approximately 0.56 with α = 0.05 (ρ = 0.4; Cohen, 1977). However, with 62 valid acculturation scores entered for mothers, power to detect a moderate effect was approximately 0.8 with α = 0.05 (ρ = 0.4; Cohen, 1977). Thus, significant results for fathers should be considered preliminary and subject to further validation with a larger sample whereas the nonsignificant results for mothers appear to be valid.
Discussion This study sought to contribute to the treatment acceptability literature by including an ethnic minority sample. The objective of this study was to compare the acceptability of different child management interventions (i.e., response cost, time-out, positive practice, token economy, differ-
treatment acceptability among mexican american parents ential attention, spanking, and medication) for socially disruptive behavior problems among Mexican American parents with children between the ages of 2 and 8 years. We were also interested in examining possible within-subgroup variability due to acculturation. Overall, Mexican American parents in this study viewed response cost, a punishment-based technique, as the most acceptable intervention for managing behavior problems. This finding seems to contradict some of the previous treatment acceptability research suggesting that parents find reinforcement-based techniques more acceptable (e.g., Jones et al., 1998). Time-out, positive practice, and token economy were also rated as being at least moderately acceptable. Although these interventions likely require a substantial amount of time and effort from parents, they were still rated as acceptable by Mexican American parents. Mexican American parents viewed differential attention, spanking, and medication as less acceptable treatment options. An important aspect of this study was assessing for acculturation. Surprisingly, the results of this study indicate that acculturation changes had little impact on treatment acceptability ratings. Differences in acceptability ratings were observed only for Mexican American fathers in that more acculturated fathers demonstrated greater acceptance of token economy as a viable treatment option. Though this relationship was found, mothers still found token economy more acceptable than fathers and fathers found spanking more acceptable than mothers. Because of the small sample of fathers included in the study, caution should be raised when interpreting this finding. One unexpected finding was that Mexican American parents did not rate differential attention as a moderately acceptable intervention. Differential attention is commonly used as a behavioral technique for increasing positive child behaviors and decreasing negative behaviors. Differential attention consists of ignoring inappropriate negative attention-seeking behavior and positively reinforcing the child for engaging in a desired appropriate behavior. From the current study, it is not exactly known what parents were responding to regarding rating the acceptability of differential attention. Perhaps parents did not like the ignoring component involved in differential attention. It might also be that differential attention needs to be role-played or modeled with parents before they have a full understanding and appreciation for why and how differential attention is used. Caution is raised for clinicians who take this as evidence that using differential attention with Mexican Amer-
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icans is not appropriate. A more detailed analysis of the acceptability of differential attention is needed before making this type of clinical decision. As suggested in previous treatment acceptability research literature, knowledge and experience seems to influence treatment acceptability (Adams & Kelly, 1992; Hobbs, Walle, & Caldwell, 1984). Furthermore, Mexican American parents in this study viewed both differential attention and spankings as similarly acceptable. The findings of this study should be viewed in the context of several limitations. First, this was an analogue study that relied on use of hypothetical vignettes rather than real-life case examples. Though the vignettes appeared to have face validity regarding a child with externalizing behavior problems, it might be that these vignettes provided limited information and may not be representative of real-world situations. As previously stated, the vignettes used in the study were adapted from the Jones et al. (1998) study in which their vignettes described a child who met diagnostic criteria for oppositional defiant disorder (ODD). Other contextual factors that might approximate a real-world situation are asking parents what they have used before in trying to correct this problem. As the literature suggests, one predictor of treatment acceptability is if the parent has had previous experience with the technique (Adams & Kelly, 1992; Hobbs et al., 1984). Second, the parents who participated in this study were a community sample. Results may be different if a clinic sample of Mexican American parents who present for services to address their child’s socially disruptive behavior problems were included. As noted in the treatment acceptability literature, behavior problem severity influences treatment acceptability (Miller & Kelley, 1992). Given that a community sample was used, social desirability may have played a role in how parents responded. Parents may have wanted to be seen in a favorable light and thus rated spanking as a less acceptable treatment option. Third, due to the significant heterogeneity among Hispanic subgroups, results might lack generalizability to other Hispanic subgroups such as Puerto Ricans, Cubans, Argentineans, etc. Therefore, this study should be replicated to see if findings are consistent across Hispanic subgroups. Related to this, the findings may not generalize to a monolingual Spanish-speaking or limited English group of Mexican Americans, such as recent immigrants (i.e., less acculturated). Future studies should focus on Spanish-speaking parents such as recent immigrants who may not be as acculturated to American culture. Fourth, this study had a relatively small sample size. This was especially
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true for fathers in our sample. Future studies should include a larger sample of fathers and examine mother-father treatment acceptance differences within the same family. This might have some clinical implications if one parent is accepting of a treatment procedure prescribed by the therapist and the other parent does not agree. Fifth, given that parents were only exposed to one child vignette in the study, there is a potential stimulus sampling problem. Finally, a different methodology should be applied in assessing treatment acceptability. As an example, most of the studies to date, including the current study, used vignettes to assess treatment acceptability. These studies imply a certain level of knowledge and understanding regarding the technique that is discussed in the vignette. Perhaps a more ecologically valid approach would be to run parents through a hypothetical scenario in which various techniques are described and parents are asked to rate their acceptability. After this baseline, parents would then be given information about each technique (e.g., differential attention) and other relevant information such as the principles involved (e.g., ignoring an inappropriate behavior can lead to extinction), what skills are needed, and what tasks are involved in carrying out the technique (i.e., what the technique looks like). Along with this information, the technique can be presented to the parent via videotape, in vivo modeling with the parent, and/or role-playing. At the end of the demonstration, parents can be asked if they have any questions or comments about the technique being discussed. At the end, parents can be assessed again on the treatment acceptability of the technique that was just covered. This seems to approximate more of what occurs when parents are given relevant information about the techniques being used as part of an intervention. As an example, Parent-Child Interaction Therapy (PCIT; Eyberg et al., 1995; Hembree-Kigin & McNeil, 1995) uses a didactic component before each treatment phases (PCIT has two treatment phases: a relationship-enhancement phase and a discipline phase). During this didactic, each technique to be used during that specific phase is discussed in detail with parents. After a discussion that includes rationales for why the technique is being used and examples, the technique is modeled for the parent and role-played with the parent. In sum, findings from this study suggest that English-speaking Mexican American parents find response cost, a punishment-based technique, as the most acceptable child management strategy. Though there was a statistical significance between response cost and the other behavioral techniques (e.g., time-out, positive reinforcement, token economy, and differential attention), it should be noted
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