Addressing Cultural Variables in Parent Training Programs With Latino Families

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Cognitive and Behavioral Practice 17 (2010) 157–166 www.elsevier.com/locate/cabp

Addressing Cultural Variables in Parent Training Programs With Latino Families Chikira H. Barker, Katrina L. Cook, and Joaquin Borrego, Jr., Texas Tech University There has recently been increased attention given to understanding how cultural variables may have an impact on the efficacy of treatments with Latino families seeking psychological services. Within parent training programs, understanding the extent to which culture can affect parenting practices is vital to providing quality care. The focus of this article is to discuss how different cultural variables such as respeto, personalismo, machismo, marianismo, and acculturation can impact the efficacy of parent training programs for Latino families. Recommendations for addressing these cultural variables in parent training programs are provided.

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our society becomes increasingly ethnically and racially diverse, there is a growing awareness for the need for culturally appropriate mental health services (American Psychological Association, 1993, 2003). Factors such as immigration status, acculturation level, and language barriers contribute to the unique mental health needs of many ethnic minority groups, including Latino populations. Latinos are now the largest ethnic minority group, comprising 14.8% of the population (U.S. Census, 2006) as high rates of immigration contribute to the continued rapid growth of Latinos in the United States. In 2007, 14% of all immigrants were individuals from Mexico (U.S. Department of Homeland Security, 2007). Considering rates of immigration, individuals of Latino descent are projected to encompass 20% of the population by the year 2030 (U.S. Census, 2004). The Latino population is the largest ethnic group and is very heterogeneous in regards to country of origin, acculturation status, socioeconomic status, and language proficiency and preference, to name a few. The need for culturally appropriate services will continue to increase as this population continues to grow. It has long been recognized that culture plays a significant role in parenting (Ogbu, 1981). Forehand and Kotchick (1996) called attention to the need for researchers and clinicians to place more emphasis on understanding the relationship between cultural factors and parent training programs targeting child behavior problems. The foundation of the authors' argument was that parent training programs cannot be examined without the consideration of culture. Given the influence S

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of culture on parenting practices, it is critical for parenting programs to address cultural factors that may affect treatment delivery and outcome. Clinical researchers have recently begun to critically examine how parent training programs can be made more culturally appropriate though the incorporation of cultural variables (e.g., Martinez & Eddy, 2005; McCabe, Yeh, Garland, Lau, & Chavez, 2005). Several recommendations have been considered in treatments with Latino clients, including the use of appropriate language; inclusion of culturally relevant values, symbols, and treatment adaptations; and addressing specific environmental stressors (i.e., discrimination, high-crime neighborhoods, language barriers) that may influence outcomes of psychological interventions (Bernal, Bonilla, & Bellido, 1995). Unfortunately, manualized treatment protocols have not adequately addressed how to take culture and related factors into account. This paper will discuss the foundations of parent training programs for young children with oppositional behavior problems. We discuss different cultural variables that have been the focus in research and clinical practice with Latino families. In addition, we discuss how to incorporate cultural variables in standardized parent training programs and emphasize other areas that require attention for clinicians and researchers in treatments for child behavior problems. We use a social validity framework to guide our clinical work in addressing cultural variables in parent training programs. Wolf (1978) introduced the concept of social validity in discussing the social significance and acceptability of interventions with different communities and populations. Within this framework, clinicians assess the social importance of the goals, procedures, and outcomes of the intervention (Foster & Mash, 1999). This framework is particularly

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relevant with ethnic and racial minority populations: Mental health professionals should not assume that an intervention deemed “effective” will work across different populations equally. Wolf identified three aspects of social validity that can be assessed by professionals. The first aspect of social validity involves examining the social significance of treatment goals. This assesses whether the identified treatment goals are significant and important for the family. The second aspect of social validity that can be assessed with different groups for cultural appropriateness pertains to the acceptability of treatment procedures. To be seen as acceptable, a treatment has to be perceived as fair, justified, and reasonable (Kazdin, 2000). The last aspect of social validity is related to the assessment of the significance of the effects of treatment. This may involve assessing the satisfaction of both the process and outcome of treatment.

Parent Training Programs A number of parent training programs have been developed with the purpose of preventing and decreasing oppositional behavior problems and increasing prosocial behaviors in children. In addition, there is a substantial body of literature documenting the efficacy of parent training programs (Brestan & Eyberg, 1998; Farmer, Compton, Burns, & Robertson, 2002). The goal of parent training is to both improve upon parents' skills and increase the consistent use of those skills. Most parent training programs are based on Patterson's model of coercive-interaction (Patterson, Chamberlain, & Reid, 1982; Patterson & Gullion, 1968) and Bandura's social learning theory (1977). The general idea behind both theories is behavioral in nature. Specifically, behaviors that are reinforced should occur more frequently in the contexts in which they are reinforced, while behaviors that are punished should occur less frequently in those contexts. Parents learn to change their own behaviors— that is, the behaviors that elicit undesirable behaviors in their children. Parents also learn to alter the consequences that they issue in response to wanted and unwanted child behaviors. Some empirically supported parent training programs that have been used with Latino families are Parent-Child Interaction Therapy (PCIT), developed by Sheila Eyberg; Parent Management Training (PMT), developed by Gerald Patterson and colleagues; and The Incredible Years, developed by Carolyn Webster-Stratton. Although other parenting programs for child behavior problems exist (e.g., Barkley, 1990; Forehand & McMahon, 1981), there is little information available regarding their applicability with Latino families. The following sections provide a brief summary of the three major parenting programs referenced previously.

Parent-Child Interaction Therapy PCIT was created as an intervention to address the disruptive behavior problems of young children within the family context (Brinkmeyer & Eyberg, 2003; Eyberg, 1988; Hembree-Kigin & McNeil, 1995). Parents practice acquired skills with their children in the context of play. What is unique about this treatment program is that the parent is coached via a “bug in the ear” while s/he interacts with the child. The treatment is completed in two phases. First, therapists focus on enhancing the parent-child relationship (e.g., increasing positive parentchild interactions) through in-vivo coaching. This component of treatment is the primary focus of the ChildDirected Interaction (CDI) phase. Once parents have mastered the skills associated with CDI, therapists move families into the Parent-Directed Interaction (PDI) phase, in which therapists coach parents on the use of developmentally appropriate discipline strategies. Although the therapy generally requires 14 weeks to complete, therapists have some flexibility regarding the rate at which families progress. PCIT has demonstrated that it is effective in reducing disruptive behavior problems in children and that these improvements remain stable over time (Capage, Bennett, & McNeil, 2001; Eyberg, et al., 2001; Hood & Eyberg, 2003; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998). Parent Management Training PMT was developed as an intervention to address coercive parent-child interactions (Kazdin & Weisz, 1998; Patterson et al., 1982). Therapists of PMT first focus on enhancing the parent-child relationship and then teach parents effective discipline skills. Parents learn through therapists' modeling of appropriate parent behaviors and role-play. Therapists provide constructive feedback to parents upon observing their practice of the skills. Although PMT is usually delivered in group format, there is flexibility in how the intervention is delivered (e.g., individual, couple, or group) as therapists typically work only with the parents (i.e., in the absence of the child). PMT has been shown to effectively reduce behavior problems in children and adolescents (Costin & Chambers, 2007; DeGarmo, Patterson, & Forgatch, 2004; Kazdin & Whitley, 2003). The Incredible Years The Incredible Years program was developed as a selective prevention program to discourage parents from using parenting techniques that may promote disruptive behavior problems in their young children (WebsterStratton, 1998). The Incredible Years is delivered to parents in a group setting where trained leaders moderate discussion after groups view video vignettes of ethnically

Cultural Variables With Latino Families diverse families interacting. The program allows for flexibility in discussion to consider the parenting values and beliefs reflected within the group. Group leaders teach parents skills that will both enhance the parentchild relationship and enable effective child management. Because The Incredible Years program is presented in a group format, the treatment is completed in 12 to 14 weeks. This program has demonstrated success in reducing child behavior problems, improving parents' child management skills, and improving teachers' classroom management skills (Reid, Webster-Stratton, & Baydar, 2004; Webster-Stratton, Reid, & Stoolmiller, 2008).

Parent Training Program Outcomes Based on Culture Recent work has focused on the applicability of these behavioral parent training interventions with ethnic minority groups, recognizing that some adaptations may need to be made (Zayas, Borrego, & DomenechRodriguez, 2009). The adaptations to these interventions range from surface-level changes (e.g., translated measures, bilingual therapists) to deep structure changes (e.g., adding a treatment component on cultural values). In one study, treatment outcome of a comprehensive intervention addressing both aggressive behaviors and difficulty in reading were compared among Hispanic and non-Hispanic early elementary school-aged children (Barrera et al., 2002). In the experimental condition, parents received The Incredible Years training while the children underwent a social behavior intervention and reading tutorials over a period of 2 years. Efforts were made to provide a culturally sensitive intervention (e.g., assessments translated to Spanish, use of bilingualbicultural staff). Children in the experimental condition demonstrated fewer externalizing behavior problems compared to children in the no-intervention control at both post-intervention and 1-year follow-up observations. Additionally, parent-rated aggressive behaviors were found to occur less frequently among treated children. Archival data were used to evaluate the effectiveness of The Incredible Years among low-income African American, Asian American, Caucasian, and Hispanic mothers (Reid, Webster-Stratton, & Beauchaine, 2001). Head Start centers were matched on community demographics (e.g., ethnic diversity, socioeconomic status), then randomly assigned to the experimental condition or control (i.e., regular Head Start program without parenting groups). Mothers in the experimental condition underwent 8 weeks of The Incredible Years parent training with the help of translators, bilingual therapists, and translated measures when appropriate. Posttreatment, the parenting of mothers assigned to the experimental condition was found to be more positive, consistent, and competent

compared to that of mothers assigned to the control group. The children of mothers who took part in the parent training displayed behavior problems less frequently than children of mothers in the control group. While no differences in treatment outcome were found across ethnic groups, and all groups rated the treatment acceptability of the program as high, Latino, African American, and Asian American parents reported less problem behaviors with their children prior to beginning treatment compared to Caucasian families. Martinez and Eddy (2005) organized and employed an extensive process of making the PMT-Oregon model more culturally appropriate for Latino families. The adaptation of this treatment package underwent an extensive review and feedback process on achieving increased cultural appropriateness. The intervention, Nuestras Familias: Andando Entre Culturas (Our Families: Moving Between Cultures), was developed for use with primarily Mexican-origin, Spanish-speaking families. In addition to keeping the core treatment components, Martinez and Eddy added treatment modules that focus on bridging two cultures, Latino roots, and the role that Latinos play in their families. When compared to a nointervention control group, parents in the culturally adapted version of PMT reported an increase in general parenting and overall parenting effectiveness. In addition, parents in the intervention group reported a decrease in child behavior problems compared to the no-intervention control. Similar adaptations have been applied to PCIT with Latino families. McCabe and colleagues (2005) adapted PCIT for families of Mexican-origin in southern California. The adapted version, Guiando a Niños Activos (GANA; Guiding Active Children), retained the core PCIT treatment components, but also referenced cultural concepts throughout treatment (McCabe & Yeh, in press). Another important feature of this program is that it did not assume a one-size-fits-all approach with all families. Instead, GANA was tailored to each individual family based on a cultural assessment (McCabe & Yeh). In a randomized clinical trial, GANA was compared to standard PCIT and a treatment as usual (TAU) condition (i.e., therapy with non-PCIT trained community therapists; McCabe & Yeh). Compared to the TAU condition, the GANA program was effective in reducing child behavior problems. In addition, the GANA treatment condition was shown to be as effective as the standard PCIT condition. Observational data suggest that parents in the GANA and standard PCIT treatment condition demonstrated a greater number of positive behaviors (e.g., praising) toward their child and fewer criticisms than parents assigned to TAU (McCabe & Yeh). Matos, Torres, Santiago, Jurado, and Rodriguez (2006) adapted PCIT for use with Puerto Rican families living in

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Puerto Rico. An initial efficacy pilot study compared an adapted version of PCIT to a wait-list condition (Matos, Bauermesiter, & Bernal, 2009). The efficacy study focused on preschool children with an ADHD diagnosis and clinically significant behavior problems. Compared to parents in the wait-list condition, parents in the PCIT condition reported a decrease in child hyperactivity and behavior problem symptoms. Parents also reported a decrease in stress related to the parent-child relationship and an improvement in parenting practices (Matos et al., 2009). In addition, Puerto Rican parents who participated in a pilot study reported finding the treatment acceptable for addressing their child behavior problems and were satisfied with the services (Matos et al., 2006). Overall, the information presented suggests that behavioral parent training programs can be used and are effective with Latino families. Although the data are promising, there is still relatively little information available to clinicians on how to address some of the cultural factors that may impact treatment. The next section will discuss how some of these important cultural factors can be addressed in treatment.

Definition of Cultural Variables Identifying unique cultural variables is important in providing therapy with ethnic minority families. This may be specifically applicable to ethnic minority parents who have either decided to immigrate to the United States or were historically forced to acclimate to the majority culture. Specific to Latino clients, several cultural variables have been identified in the literature. While the origin of some variables is unknown, it is likely that these variables have developed from values indigenous to their respective countries of origin, in addition to being a reaction to adjusting to the American culture. In this next section, we will discuss several variables that are important to consider when working with Latino clients. Additionally, we will discuss how these variables may impact the implementation of parent training programs for young children. Cultural Variables The cultural variable of respeto focuses on having respect and empathy within interpersonal relationships (Andrés-Hyman, Ortiz, Añez, Paris, & Davidson, 2006). In the context of parenting, respeto stresses the importance of having children obey authority figures (e.g., parents and grandparents). Similarly, personalismo is a variable that focuses on having trust and warm interpersonal interactions with others (Altarriba & Santiago-Rivera, 1994). Within therapy, these variables have been discussed regarding the therapeutic relationship, emphasis on reciprocity of respect between clinicians and clients, treating clients with dignity, and ensuring that therapists work to build strong and warm relationships with Latino

clients. These variables are integral to parenting programs because changes in children's behavior are contingent upon parents' successful acquisition and use of skills learned over the course of treatment. Familismo or familism focuses on “attachments, reciprocity, and loyalty to family members beyond the boundaries of the nuclear family” (Andrés-Hyman et al., 2006). In the context of parent training programs, the degree of familism has been found to be associated with parental practices and treatment acceptability. Romero and Ruiz (2007) found that familism was associated with more consistent discipline and increased parental monitoring. Similarly, overall scores for familismo (defined by family as referents, familial obligations, and perceived family support) was predictive of acceptability of discipline techniques for Hispanic families, but not Caucasian families (Pemberton & Borrego, 2007). Thus, familismo appears to be a construct with major consequences concerning parenting techniques and may have some bearing on behavior problems in young children as well. In addition, familismo may have an impact on who is also sharing in the parenting and discipline responsibilities (e.g., aunt, grandmother). Machismo and marianismo are variables based on gender roles within family dynamics. Machismo is defined in terms of fathers being the head of the family, specifically making key decisions for the family unit. Males high in machismo are considered to be independent, courageous, and possess strength of character (AndrésHyman et al., 2006). Marianismo surrounds women making sacrifices and providing care for her children and husband (Altarriba & Santiago-Rivera, 1994). Clinically, it has been hypothesized that qualities of machismo may relate to being less willing to seek psychological services (Cuéllar, Arnold, & González, 1995); thus, with a machismo father, the odds of a family seeking services for their children may decrease. Research examining gender role discrepancies with adolescents (Céspedes & Huey, 2008) found that greater gender role discrepancies were associated with more depressive symptoms, family conflict, and low familial cohesiveness. Thus, clinicians would benefit from further considering how departure from gender roles may impact functioning within parent training programs, particularly for mothers who may be participating in treatment. One area that has demanded a significant amount of attention is the examination of acculturation and acculturative stress. Acculturation can be defined as adjustments or changes made by an individual as they become immersed in a different culture (Cabassa, 2003), whereas acculturative stress can be defined as individual and familial stress associated with adjustments to a new culture. Increases in acculturative stress have been associated with difficulty in obtaining resources, adjusting to a new language, and familial conflict for Latino adults

Cultural Variables With Latino Families (Miranda & Matheny, 2000). Higher levels of acculturative stress have been found to be related to increases in depression, suicidal ideation, and decreases in family cohesion (Hovey & King, 1996). There is some evidence to suggest that acculturative stress levels impact other important cultural variables. Cuéllar and colleagues (1995) found that as Mexican-Americans become more acculturated to American culture, adherence to cultural values such as familismo and machismo decreases. Research suggests that the process of acculturation can influence parenting practice as well. Acculturation has been found to affect childrearing (Delgado-Gaitan, 1993) and discipline strategies (Buriel, Mercado, Rodriquez, & Chavez, 1991). As it pertains to parenting in Latino families in the United States, researchers have found differences in parenting practices between Englishspeaking and Spanish-speaking Mexican-American parents (Hill, Bush, & Roosa, 2003). Similarly, Varela and colleagues (2004) found that Mexican immigrants and Mexican-American parents had a more authoritarian parenting style compared to Mexican parents in Mexico. Thus, examining the relationship between acculturation and parenting may prove to be essential as it could influence outcomes in treatment programs based on goals consistent with European-American values, versus goals that may be more relevant to other cultural groups. Clinical Recommendations While it is important to understand and acknowledge culturally relevant variables when working with Latino families in parent training programs, understanding how these variables may influence the conceptualization of cases or how they should be considered within treatment continues to be a question for clinicians. Clinicians should be aware that not all Latinos adhere to the same cultural factors and not all adhere to the same extent. This is an important point as this allows the therapist to use these factors in hypothesis formulation. In addition, having this information helps minimize stereotypes about individuals who belong to a socially defined group. As discussed earlier, there is extreme heterogeneity with regard to the extent to which individuals adhere to different cultural factors such as respeto and familismo. Differing levels of acculturation and degrees of ethnic identity may affect how much a person adheres to these cultural factors. In the following section, we will discuss how we address these variables in the context of parent training programs. Language Perhaps the first concern that occurs to therapists providing service is that of language. When should therapists refer families to other clinicians who are able to provide services in Spanish? This decision is based on

the language preference of the client and the language proficiency of the therapist. If a family prefers or is more proficient in Spanish and a therapist is more proficient in English, clinicians are encouraged to consider transferring the family to another therapist or using a translator. This same guideline applies to the use of assessment instruments. Although validated instruments are becoming readily available in Spanish, clinicians may not have easy access to such instruments. If a family prefers or is more proficient in Spanish, the use of an assessment instrument in Spanish is warranted. Respeto Several recommendations have been made to address this variable in treatment. Andrés-Hymen and colleagues (2006) suggested that therapists can be sensitive to respeto by initially addressing clients by their last name (e.g., Therapist: “How would you like for me to address you? Mrs. Rodriguez?”) and incorporating culturally related material within the treatment process (e.g., translation of documents into Spanish, making bilingual therapists available, Spanish reading material, and culturally appropriate artwork). Several parent training programs have incorporated these recommendations into their treatments with Latino clients (e.g., Barrera et al., 2002; Borrego, Anhalt, Terao, Vargas, & Urquiza, 2006; Matos et al., 2006; McCabe et al., 2005). Other suggestions focused on therapists communicating with their clients about the nature of treatment and explaining the role of the therapist (AndrésHymen et al., 1996; McCabe et al., 2005). In terms of respeto, we would argue that it is also important to consider how respeto may play a role within the parent-child relationship of clients in treatment. As stated above, in the context of respeto, there may be an emphasis on having children behaving properly in public and conforming to authority figures (e.g., adults). Within the Latino culture, adults place a high priority on children being obedient, polite, and respectful (Arcia & Johnson, 1998). Because respeto is a highly valued variable within the Latino culture, therapists may find it beneficial to emphasize aspects of treatment that will promote improvements in obedience and manners. For example, therapists should encourage parents to provide praise for using manners, especially in the presence of other adults: CHILD (C): Mamí, can you please pass me the blue marker? PARENT (P): What great manners, Benito! I bet your teacher loves when you are polite in class. THERAPIST (T): Benito, you did a great job of asking your mamí for the blue marker! T: Mrs. Rodriguez, I really like the way you praised your child and showed him cariños by giving him a big hug.

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Barker et al. Depending on the treatment used, therapists could assist parents by modeling this skill in the therapy room. One way that this has been incorporated into coaching skills is to have the parent engage in a skill-building exercise in which they are to practice for a finite amount of time within therapy and at home to provide praise each time the child is polite or respectful. It is also important to assess for what other types of reinforcers the family is likely to use. For example: T: Alright, Mrs. Rodriguez, let's see how many times you can praise your son in the next minute. T: Please remember, a praise is one way of showing cariños. You can also show cariños by giving him a hug and patting his back. In the context of social validity, there may be instances in which a parent may question the treatment acceptability of a procedure: T: Mrs. Rodriguez, today we'll be talking about what we call “active ignoring.” P: Active ignoring? Why would I want to ignore my child? T: This procedure is sometimes taught to parents. Basically, in active ignoring, the parent ignores the child when misbehaving. In turn, the parent provides lots of positive attention when the child is behaving appropriately. P: I do not think I would want to ignore my child when they are misbehaving, such as hitting my youngest or yelling at me. That is very disrespectful to me. T: Mrs. Rodriguez, I certainly understand your hesitation about this technique. I can explain in more detail what is involved. I can also show you how it is done, and you and I can practice. If you are still uncomfortable with the idea, we can try something else that would work for you and your family. There is some research to suggest that differential attention, a behavioral parenting technique that is often taught to parents, may not be as acceptable as a treatment strategy with Mexican-American parents (Borrego, Ibanez, Spendlove, & Pemberton, 2007). Other strategies, such as response cost and time-out, may be more acceptable for Mexican-American parents (Borrego et al.). This highlights the fact that not all techniques that have empirical evidence will be acceptable to parents. Personalismo How should a therapist react if a parent requests that the child kiss the therapist on the cheek at the end of a session? What should you do if you are invited to a family function? Over the course of treatment, the therapist may

be unsure of how to address issues related to professional boundaries within the therapeutic relationship. Issues such as these can present some discomfort, particularly for new therapists who are trying to balance building a relationship with their client with the ethical responsibility to maintain appropriate boundaries. At the beginning of treatment, therapists should work to establish a relationship with their clients. Many parent training programs have recommended allotting extra time at the beginning of session to discuss concerns unrelated to the child (e.g., T: So, Mrs. Rodriguez, last week you mentioned spending some time caring for your niece. Has she gotten over the flu yet?) (Matos et al., 2006; McCabe et al., 2005). Some self-disclosure, related or unrelated to treatment, especially if you have had similar experiences in your own child-rearing, may help families feel that you relate to their experiences in dealing with their child's behavior. P: You should have seen him. He was on the floor of the grocery store in the checkout line screaming about candy! T: Oh, I know, both my son and daughter have done that in the past. Therapists may also want to conduct a “check-in” phone call at least once during the initial weeks of treatment to ask parents about their ability to use the skills at home or any specific difficulties they are having that may be related to the child's behavior. This may be especially useful in building the therapist-client relationship as well as possibly providing additional social support if needed. In terms of balancing boundaries, two areas that may be especially concerning to new therapists is the issue of physical contact and invitations to social and cultural events. When working with young children, there is a good probability that the child will want to initiate physical contact (i.e., hugs, kisses, requests to sit on your lap). For the most part, it is the therapist's discretion to decide their level of comfort with physical contact from the child, or, at times, the parents. As therapists become closer with families, there may be invitations to family events (e.g., birthday parties). While attendance to these is essentially up to the therapist, there may be reservations in engaging in a behavior that could blur relationship boundaries and threaten confidentiality when in public. One alternative that is used with increasing frequency in treatment is offering to provide the family with a home visit at some stage during therapy. A home visit would be similar to a therapy session that takes place at the client's home. This would allow a closer interaction with the client while maintaining comfortable boundaries within the therapeutic relationship. Working with the family at their home would also add to the ecological validity of the intervention.

Cultural Variables With Latino Families Familismo Within treatment, it will be especially important for the therapist to consider the influence that extended family and friends may have within the parent-child dynamic, as well as successful completion of treatment. During the pretreatment assessment, we recommend that therapists also gain information about how extended family members may handle issues related to the child. Is the child defiant with other family members? If so, how do these individuals handle the child's behavior? Understanding that the child may spend a significant amount of time with extended family members, the therapist may want to encourage the parent to include these family members within treatment. In Latino communities, there is often a stigma associated with seeking therapeutic services. Hence, parents may not receive support from extended family members in their decision to begin a parent training program. A concern for many clients is how to best explain therapy to family members. In the case that this is in fact a concern, we recommend that the therapist help the client to problemsolve ways of explaining therapy to close family members. For example, some parents find it useful to tell family that they are attending parenting classes and invite them to attend. In these cases, therapists should include family members in treatment. McCabe and colleagues (2005) suggested providing psychoeducation for the client's family members about the nature of treatment. An example exchange between a parent and therapist may proceed as follows: T: What is something that your son does that really upsets you? P: He is very disrespectful and doesn't do what I tell him to do. When I ask him to play nicely with his sister, he takes her toys and throws them across the room. T: Have you noticed that he acts this way during certain times, in certain places, or around certain people? P: Yes—he mostly acts out in front of his primos [cousins] and tios [uncles]—when we are with family. T: What does your family say about his behavior? P: They say that he is just a strong-willed boy and that I should keep praying for him to be good. T: What do they say about you coming to get help with your son's behavior here at the clinic? P: I haven't talked to them about that because I don't think they will understand. T: Well, maybe we can talk about some different ways to talk to them about it. One concern that has been expressed by many of our clients is the relationship between children receiving treatment and their siblings. Many parents worry that the

arguing and physical aggression in which children and their siblings engage may damage their relationships with one another in the future. Because Latino clients do place a high value on the relationship they have within their families, it may be useful to work with parents on improving children's relationships with their siblings. One way to accomplish this goal could be to use a token economy system to help children earn rewards for engaging in prosocial behaviors with siblings and parents. This can be adjusted so that all of the siblings can help to earn a family reward (e.g., going to the park, getting ice cream, seeing a movie) by increasing prosocial behaviors with one another. Machismo and Marianismo To our knowledge, parent training programs have not directly addressed how gender roles may impact parent training programs. Therapists will have to carefully consider how the cultural views of gender roles may influence parent training programs. For example, a mother may always defer to the father to discipline the children because he is the head of the household. Thus, it may be a challenge to encourage the mother to assume more responsibility for discipline, despite her concerns with the child not being respectful. Conversely, the father may leave the discipline of the children to the mother because it may be viewed as her primary responsibility. In terms of parent training, this may lead the father to have little involvement in the therapeutic process, especially if he feels that he is overstepping his role in childrearing. At the beginning of treatment, therapists should ask questions regarding each parent's participation in interacting with the child. For example, who tends to discipline the children? How would the children react if they were disciplined by the other parent? If both parents are present, this would be an ideal time for the therapist to investigate any discomfort in providing discipline to the children. Perhaps the father is uncomfortable with disciplining his daughter, but not his son. Therapists may need to provide some psychoeducation regarding the importance of consistent discipline from both parents. It may be necessary to engage in more rigorous skillsbuilding for the parent that defers disciplining to their partner. These parents may need more encouragement in consistently following through with discipline and may need more support if they receive more acting-out behavior as a result of them becoming a disciplinarian. Within treatment, it may also be helpful to encourage the parents to be supportive of one another as they acquire the skills. An example of how a therapist may engage a mother who is attending treatment without her husband, the child's father, follows: T: Mrs. Rodriguez, how do you feel about using timeout with your son?

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Barker et al. C: I think I can do it, but I don't know how I'm going to explain it to my husband. He will say that it's not a punishment that will make him into a strong man. T: You've told me before that your husband makes all of the big decisions for the family outside of the home and you take care of everything in the home, including the discipline of your children. You've also told me that sometimes he will have you do things differently at home when something is not working or he has another idea of a way that might work better. I wonder what he would say if you said, “I would like to try using time-out for a few weeks to see if it works for our family.” P: He would probably say that that would be okay, but he might not want to do it himself. T: Maybe then you could talk to him about how it might relieve some of your nerves, especially if you could feel like he is supportive of you and what you're trying to do— raise your son up to be a strong man. This is also a good illustration of addressing social validity of an intervention by discussing the social significance of treatment goals. If a therapist determines that a treatment goal is to reduce a child's socially disruptive behavior problems, would the family agree as this being the priority goal for treatment? It may be that the family is more interested in having their child buen educado (socially well educated) when interacting with other adults and family members (e.g., displaying manners and being obedient in front of adults). Acculturation To consider acculturation within parent training, we recommend gathering information on acculturation level as well as acculturative stress prior to beginning treatment. This is recommended because acculturation and acculturative stress can be a primary factor in the level of adherence to cultural variables, a stressor related to parenting or family support, and a potential contributor to the child's behavior problems. For example, parents may also experience parenting stress as it relates to their cultural experiences with rearing their young child in the United States. Parents may be hesitant to interact with school officials or feel uncomfortable with school recommendations for controlling child behavior problems. Likewise, parents of young children, particularly if the child attends elementary school, preschool, or daycare, may begin to experience a clash of cultures as younger children tend to acclimate to new cultures more quickly than parents. Within treatment, it may be necessary to allot some time to assist parents in navigating the cultural changes that their children will begin to display.

Similarly, parental acculturative stress may have an impact on the development of behavior problems in preschoolers. Within treatment, it is important for therapists to thoroughly assess significant stressors for the family, specifically for families that have recently immigrated to the United States. In the situation in which the family has recently immigrated, therapists may need to help families access resources to alleviate the strain associated with relocating. Assessment measures such as the Acculturation Rating Scale for Mexican Americans–II (ARMSA-II; Cuéllar, Arnold, & Maldonado, 1995), the Short Acculturation Scale for Hispanics (SASH; Marín, Sabogal, VanOss Marín, Otero-Sabogal, & Pérez-Stable, 1987), or the Bidimensional Acculturation Scale for Hispanics (BAS; Marín & Gamba, 1996) can be used with parents to assess acculturation levels. Related assessments, such as the Societal Attitudinal, Familial, and Environmental, Acculturative Stress Scale (SAFE; Padilla, Wagatsuma, & Lindholm, 1985), can provide some clarity regarding the relevance of these variables within families. The benefit of using assessments is that you can obtain information regarding the extent to which a person ascribes to views of their native culture compared to the majority culture. Similarly, assessments, in addition to treatment, can allow a critical evaluation of the extent to which a wide variety of potential stressors may affect daily living. As with other forms of assessment, it is the therapist's responsibility to assess the client's English language proficiency or language preference. When working with Latino populations, it may be useful to use a 5-point scale to assess language preference and/or proficiency: English only; Bilingual, but mainly English; Equally Bilingual; Bilingual, but mainly Spanish; and monolingual Spanish. Using these descriptors can help clinicians gauge if Spanish-version instruments or a translator should be used.

Conclusion This article discussed cultural variables as they related to Latino families participating in parent training programs for young children with behavior problems. While clinical researchers have taken great strides to investigate the importance of cultural variables in treatment, the paucity of research in this area, particularly as it relates to treatments with young children, leaves practicing therapists to rely on their clinical judgment to adjust parenting programs in order to provide the most effective treatments for clients from different cultural groups. Our recommendation is for clinicians to assess the clients' adherence to traditional cultural variables in addition to acculturation and acculturative stress with the understanding that not all Latino families will adhere to the same cultural variables to the same extent. This

Cultural Variables With Latino Families information may provide clinicians with the knowledge required to determine possible adjustments to parent treatment protocols, though changes must be made carefully so as not to harm the integrity of these evidence-based interventions. For clinicians unsure of what changes should be made, we not only recommend consulting with experts in the field, but also encourage clinicians to communicate with clients about how they propose to address concerns within treatment. Through this method, clinicians can elicit feedback from parents about any specific concerns with changes to the traditional treatment. In addition, clinicians are encouraged to follow the guidelines that have been developed for working with ethnic and racially diverse clients (American Psychological Association, 1993, 2003). This includes an ethical component: recognizing when a family may need to be referred to another clinician, one who may be able to provide more culturally appropriate assessment and/or services based on language and/or other culture variables. Finally, assessing for the impact of these cultural variables can increase the social validity of an intervention with Latino families.

References Altarriba, J., & Santiago-Rivera, A. L. (1994). Current perspectives on using linguistic and cultural factors in counseling the Hispanic client. Professional Psychology: Research and Practice, 25, 388–397. American Psychological Association. (1993). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. American Psychologist, 48, 45–48. American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377–402. Andrés-Hyman, R. C., Ortiz, J., Añez, L. M., Paris, M., & Davidson, L. (2006). Culture and clinical practice: Recommendations for working with Puerto Ricans and other Latinas(os) in the United States. Professional Psychology: Research and Practice, 37, 694–701. Arcia, E., & Johnson, A. (1998). When respect means to obey: Immigrant Mexican mother's values for their children. Journal of Child and Family Studies, 7, 79–95. Bandura, A. (1977). Social learning theory. Oxford, England: PrenticeHall. Barkley, R. A. (1990). Attention-deficit/hyperactivity disorder: A handbook for diagnosis and treatment. New York: Guilford Press. Barrera, M., Biglan, A., Taylor, T. K., Gunn, B. K., Smolkowski, K., Black, C., et al. (2002). Early elementary school intervention to reduce conduct problems: A randomized trial with Hispanic and non-Hispanic children. Prevention Science, 3, 83–94. Bernal, G., Bonilla, J., & Bellido, C. (1995). Ecological validity and cultural sensitivity for outcome research: Issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23, 67–82. Borrego, J., Anhalt, K., Terao, S. Y., Vargas, E. C., & Urquiza, A. J. (2006). Parent-child interaction therapy with a Spanish-speaking family. Cognitive and Behavioral Practice, 13, 121–133. Borrego, Jr., J., Ibanez, E. S., Spendlove, S. J., & Pemberton, J. R. (2007). Treatment acceptability among Mexican American parents. Behavior Therapy, 38, 218–227. Brestan, E. V., & Eyberg, S. M. (1998). Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. Journal of Clinical Child Psychology, 27, 180–189. Brinkmeyer, M., & Eyberg, S. M. (2003). Parent-child interaction therapy for oppositional children. In A. E. Kazdin, & J. R. Weisz

(Eds.), Evidence-based psychotherapies for children and adolescents (pp. 204–223). New York: Guilford. 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. Cabassa, L. J. (2003). Measuring acculturation: Where we are and where we need to go. Hispanic Journal of Behavioral Sciences, 25, 127–146. Capage, L. C., Bennett, G. M., & McNeil, C. B. (2001). A comparison between African American and Caucasian children referred for treatment of disruptive behavior disorders. Child & Family Behavior Therapy, 23, 1–14. Céspedes, Y. M., & Huey, S. J. (2008). Depression in Latino adolescents: A cultural discrepancy perspective. Cultural Diversity and Ethnic Minority Psychology, 14, 168–172. Costin, J., & Chambers, S. M. (2007). Parent Management Training as a treatment for children with oppositional defiant disorder referred to a mental health clinic. Clinical Child Psychology and Psychiatry, 12, 511–524. Cuéllar, I., Arnold, B., & González, G. (1995). Cognitive referents of acculturation: Assessment of cultural variables in Mexican Americans. Journal of Community Psychology, 23, 339–356. Cuéllar, I., Arnold, B., & Maldanado, R. (1995). Acculturation rating scale for Mexican-Americans-II: A revision of the original ARMSA scale. Hispanic Journal of Behavioral Sciences, 17, 275–304. DeGarmo, D. S., Patterson, G. R., & Forgatch, M. S. (2004). How do outcomes in a specified parent training intervention maintain or wane over time? Prevention Science, 5, 73–89. Delgado-Gaitan, D. (1993). Parenting in two generations of Mexican American families. International Journal of Behavioral Development, 16, 409–427. Eyberg, S. M. (1988). Parent-child interaction therapy: Integration of traditional and behavioral concerns. Child & Family Behavior Therapy, 10, 33–46. Eyberg, S. M., Funderburk, B. W., Hembree-Kigin, T. L., McNeil, C. B., Querido, J. G., & Hood, K. (2001). Parent-child interaction therapy with behavior problem children: One and two year maintenance of treatment effects in the family. Child & Family Behavior Therapy, 23(4), 1–20. Farmer, E. M. Z., Compton, S. N., Burns, B. J., & Robertson, E. (2002). Review of the evidence base for treatment of childhood psychopathology: Externalizing disorders. Journal of Consulting and Clinical Psychology, 70, 1267–1302. Forehand, R., & Kotchick, B. A. (1996). Cultural diversity: A wake-up call for parenting training. Behavior Therapy, 27, 187–206. Forehand, R. L., & McMahon, R. J. (1981). Helping the noncompliant child: A clinician's guide to parent training. New York: Guilford Press. 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. Hembree-Kigin, T., & McNeil, C. (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. Hood, K., & Eyberg, S. M. (2003). Outcomes of parent-child interaction therapy: Mother's reports on maintenance three to six years after treatment. Journal of Clinical Child and Adolescent Psychology, 32, 419–429. Hovey, J. D., & King, C. A. (1996). Acculturative stress, depression, and suicidal ideation among immigrant and second-generation Latino adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1183–1192. Kazdin, A. E. (2000). Perceived barriers to treatment participation and treatment acceptability among antisocial children and their families. Journal of Child and Family Studies, 9, 157–174. Kazdin, A. E., & Weisz, J. R. (1998). Identifying and developing empirically supported child and adolescent treatments. Journal of Consulting and Clinical Psychology, 66, 19–36. Kazdin, A. E., & Whitley, M. K. (2003). Treatment of parental stress to enhance therapeutic change among children referred for

165

166

Barker et al. aggressive and antisocial behavior. Journal of Consulting and Clinical Psychology, 71, 504–515. Marín, G., & Gamba, R. J. (1996). A new measurement of acculturation for Hispanics: The Bidimensional Acculturation Scale for Hispanics (BAS). Hispanic Journal of Behavioral Sciences, 18, 297–316. Marín, G., Sabogal, F., VanOss Marín, B., Otero-Sabogal, R., & PérezStable, E. J. (1987). Development of a short acculturation scale for Hispanics. Hispanic Journal of Behavioral Sciences, 9, 183–205. Martinez, C. R., & Eddy, J. M. (2005). Effects of culturally adapted parent management training on youth behavioral health outcomes. Journal of Consulting and Clinical Psychology, 73, 841–851. Matos, M., Bauermesiter, J. J., & Bernal, G. (2009). Parent-child interaction therapy for Puerto Rican preschool children with ADHD and behavior problems: A pilot efficacy study. Family Process, 48, 233–253. Matos, M., Torres, R., Santiago, R., Jurado, M., & Rodriguez, I. (2006). Adaptation of Parent-Child Interaction Therapy for Puerto Rican families: A preliminary study. Family Process, 45, 205–222. Miranda, A. O., & Matheny, K. B. (2000). Socio-psychological predictors of acculturative stress among Latino adults. Journal of Mental Health Counseling, 22, 306–317. McCabe, K. M., & Yeh, M. (in press). Parent-child interaction therapy for Mexican Americans: A randomized clinical trial. To appear in Journal of Clinical Child and Adolescent Psychology. McCabe, K. M., Yeh, M., Garland, A. F., Lau, A. S., & Chavez, G. (2005). The GANA program: A tailoring approach to adapting parentchild interaction therapy for Mexican Americans. Education and Treatment of Children, 28, 111–129. Ogbu, J. U. (1981). Origins of human competence: A culturalecological perspective. Child Development, 52, 413–429. Padilla, A. M., Wagatsuma, Y., & Lindholm, K. J. (1985). Acculturation and personality as predictors of stress in Japanese and JapaneseAmericans. The Journal of Social Psychology, 125, 295–305. Patterson, G. R., Chamberlain, P., & Reid, J. B. (1982). A comparative evaluation of a parent training program. Behavior Therapy, 13, 638–650. Patterson, G. R., & Gullion, M. E. (1968). Living with children: New methods for parents and teachers. Champaign, IL: Research Press. Pemberton, J. R., & Borrego, J. (2007). Increasing acceptance of behavioral child management techniques: What do parents say? Child & Family Behavior Therapy, 29, 27–45. Reid, M. J., Webster-Stratton, C., & Baydar, N. (2004). Halting the development of conduct problems in Head Start children: The effects of parent training. Journal of Clinical Child and Adolescent Psychology, 33, 279–291. Reid, M. J., Webster-Stratton, C., & Beauchaine, T. P. (2001). Parent training in Head Start: A comparison of program response among

African American, Asian American, Caucasian, and Hispanic mothers.. Prevention Science, 2, 209–227. Romero, A. J., & Ruiz, M. (2007). Does familism lead to increased parental monitoring?: Protective factors for coping risky behaviors. Journal of Child and Family Studies, 16, 143–154. Schuhmann, E. M., Foote, R., Eyberg, S. M., Boggs, S., & Algina, J. (1998). Parent-child therapy: Interim report of a randomized trial with short-term maintenance. Journal of Clinical Child Psychology, 27, 34–45. U.S. Census Bureau, (2006). American community survey. Retrieved June 5, 2008, from http://www.census.gov/acs/www/index.html. U.S. Census Bureau, (2004). U.S. interim projections by age, sex, race, and Hispanic origin: 2000-2050. Retrieved June 5, 2008, from http: //www.census.gov/ipc/www/usinterimproj. U.S. Department of Homeland Security, (2007). U.S. legal permanent residents: 2007. Retrieved June 24, 2008, from http://www.dhs. gov/ximgtn/statistics/. Varela, R. E., Vernberg, E. M., Sanchez-Sosa, J. J., Riveros, A., Mitchell, M., & Mashunkashey, J. (2004). Parenting style of Mexican, Mexican American, and Caucasian-Non-Hispanic families: Social context and cultural influences.. Journal of Family Psychology, 18, 651–657. Webster-Stratton, C. (1998). Preventing conduct problems in Head Start children: Strengthening parenting competencies. Journal of Consulting and Clinical Psychology, 66, 715–730. Webster-Stratton, C., Reid, M. J., & Stoolmiller, M. (2008). Preventing conduct problems and improving school readiness: Evaluation of the Incredible Years teacher and child training programs in high-risk schools. Journal of Child Psychology and Psychiatry, 49, 471–488. Wolf, M. (1978). Social validity: The case for subjective measurement. Journal of Applied Behavior Analysis, 11, 203–214. Zayas, L. H., Borrego, Jr. J., & Domenech-Rodríguez, M. (2009). Parenting interventions and Latino families: Research findings, cultural adaptations, and future directions. In F. Villarruel, G. Carlo, J. M. Grau, M. Azmitia, N. Cabrera, and J. Chahin (Eds.), U.S. Handbook of Latino Psychology: Developmental and Community Based Perspectives, (pp. 291–308) Newbery, CA: Sage Publications.

Support for this work was supported in part by a National Institute of Mental Health (NIMH) grant (R13 MH077403) awarded to Dr. Luis H. Zayas. Address correspondence to Joaquin Borrego, Jr., Ph.D., Department of Psychology, Texas Tech University, Lubbock, TX 79409-2051; e-mail: [email protected]. Accepted: January 12, 2010 Available online 4 March 2010