Caregiver Participation Engagement in Child Mental Health Prevention Programs: a Systematic Review.

Prevention programs are a key method to reduce the prevalence and impact of mental health disorders in childhood and adolescence. Caregiver participation engagement (CPE), which includes caregiver participation in sessions as well as follow-through with homework plans, is theorized to be an important component in the effectiveness of these programs. This systematic review aims to (1) describe the terms used to operationalize CPE and the measurement of CPE in prevention programs, (2) identify factors associated with CPE, (3) examine associations between CPE and outcomes, and (4) explore the effects of strategies used to enhance CPE. Thirty-nine articles representing 27 unique projects were reviewed. Articles were included if they examined CPE in a program that focused to some extent on preventing child mental health disorders. There was heterogeneity in both the terms used to describe CPE and the measurement of CPE. The majority of projects focused on assessment of caregiver home practice. There were no clear findings regarding determinants of CPE. With regard to the impact of CPE on program outcomes, higher levels of CPE predicted greater improvements in child and caregiver outcomes, as well as caregiver-child relationship quality. Finally, a small number of studies found that motivational and behavioral strategies (e.g., reinforcement, appointment reminders) were successful in promoting CPE. This review highlights the importance of considering CPE when developing, testing, and implementing prevention programs for child mental health disorders. Increased uniformity is needed in the measurement of CPE to facilitate a better understanding of determinants of CPE. In addition, the field would benefit from further evaluating strategies to increase CPE as a method of increasing the potency of prevention programs.

Multistakeholder Etiological Explanation Agreement and Adolescent/Parent Treatment Engagement.

Client-therapist consensus has been hypothesized to be an important element of culturally competent care. However, little is known about the relationship between explanatory model agreement and treatment engagement, particularly for services involving adolescents, where both parent and youth perspectives may need to be considered. This longitudinal study collected youth, parent, and therapist survey data on etiological beliefs as well as therapist-rated treatment engagement related to a culturally diverse sample of 285 outpatient mental health service-using youth (aged 12-18, M = 14.06 at Time 1 interview; 40% female). Youth-therapist and parent-therapist agreement on beliefs about the etiology of the youth's mental health problems were examined in relationship to later treatment engagement. Although parent-therapist agreement was unrelated to parent engagement, youth-therapist coendorsement of etiological beliefs predicted overall youth treatment engagement. In addition, youth-therapist agreement significantly predicted specific aspects of youth engagement: client-therapist interaction, communication/openness, and client's perceived usefulness of treatment. Results speak to the importance of agreement between therapist and youth upon key issues related to the youth's problems in mental health treatment settings and support facilitation of consensus as a component of culturally competent care. Differences between findings for youth and parents suggest that therapeutic relationships may vary for different stakeholders, indicating a need to consider individual perspectives and contributions separately.

Sociocultural Factors and Parent-Therapist Agreement on Explanatory Etiologies for Youth Mental Health Problems.

Sociocultural factors were examined in relationship to parent-therapist agreement on beliefs about the etiology of mental health problems in a sample of youth receiving outpatient mental health services (n = 277 parents). When examined individually, racial/ethnic match was unrelated, but higher parental affinity to mainstream American culture, higher parent education level, and greater similarity in parent and therapist scores on affinity to mainstream American culture were all significantly associated with greater parent-therapist co-endorsement of etiological explanations, while higher parental affinity to an alternative/indigenous culture was significantly associated with lower co-endorsement. When examined simultaneously in one model, only parent education level remained significantly associated. Findings suggest a complex relationship between sociocultural factors and that attention to parent cultural affinity and parent education level may facilitate parent-therapist agreement on beliefs about child problem causes.

Parental etiological explanations and longitudinal medication use for youths with attention deficit hyperactivity disorder.

Due to the need to increase understanding of factors associated with medication usage for youth with ADHD, this study examined parental explanatory etiologies in relationship to psychotropic medication use in a sample of youth who met criteria for ADHD and utilized outpatient specialty mental health services in the previous year. When examined cross-sectionally, medication usage was positively associated with parental explanatory etiologies related to physical causes and negatively associated with those involving sociological causes. Longitudinal analyses did not show a significant effect of Time 1 parental explanatory etiologies on the slope of medication use, suggesting that the relationship between Time 1 parental explanatory etiologies and medication usage remains stable over time for those who have had past year involvement with outpatient specialty mental health services.

Parent Explanatory Model Personalization as a Method of Reducing Risk for Poor Engagement and Outcomes in PCIT among Culturally Diverse Families.

Background/Objectives: Evidence supports the efficacy of Behavioral Parent Training (BPT) interventions such as Parent-Child Interaction Therapy (PCIT) for treating child behavior problems; however, treatment engagement and outcomes vary across ethnic groups. Risk for poor treatment engagement and outcomes may be attributed in part to misalignment between parent explanatory model components (PEMs) and the traditional BPT model, including treatment expectations, etiological explanations, parenting styles, and family support for treatment. The present study aims to examine whether personalized treatment adaptations addressing these PEM-BPT misalignments reduce risk for poor treatment engagement and outcomes. Methods: The authors previously utilized the PersIn framework to develop a personalized version of PCIT (MY PCIT) that assesses these PEMs in order to identify families at risk for poor treatment engagement and outcomes. Families were identified as high risk (due to PEM-BPT misalignment) and low risk (meaning those without identified PEM-BPT misalignment) for specific PEMs. Families at elevated risk then received tailored treatment materials designed to improve alignment between the parental explanatory model and the PCIT treatment explanatory model. A recent pilot trial of MY PCIT demonstrated positive treatment outcomes; however, the extent to which adaptations were successful in reducing the underlying risk factors has not yet been examined. Results: Findings demonstrate that the personalization approach was effective in reducing indicators of risk, and that families who were initially at high and low risk during pre-treatment reported similar levels of treatment engagement and outcomes by post-treatment. Conclusions: The findings suggest that this personalized approach has the potential to reduce risk associated with poor treatment engagement and outcomes for culturally diverse families.

The latent structure of the Delis-Kaplan system for autism.

A core feature of autism is deficits in executive functioning (EF), including difficulty with planning, cognitive flexibility, and working memory. Despite a growing need for evidence-based assessments of EF for autism populations, statistical models of many commonly used measures of EF, including the Delis-Kaplan Executive Function System (D-KEFS), have not been investigated for a sample of autistic participants. The purpose of this study was to address a gap in the literature regarding the latent structure of the D-KEFS in a sample of autistic individuals. The D-KEFS is one of the most widely used clinical assessments of executive function, but its factor structure has not been examined in a sample of autistic participants. Reliability analyses were performed for sample subgroups based on participants' clinical and demographic characteristics, including IQ, autism severity, age, and race/ethnicity. Verbal Fluency (VF) was found to consistently decrease or not affect the overall reliability score. Additionally, one- and two-factor structure models were tested for the D-KEFS with a sample of autistic participants. The one-factor model was not found to be a good fit for the data. However, the two-factor model, with Cognitive Flexibility and Abstraction latent factors, was found to fit the data relatively well. This two-factor model was reexamined excluding the VF observed variable, resulting in a better overall model fit. Communication deficits are a common feature of autism, which explains why the VF task, that requires participants to produce novel words, may not be an adequate measure of executive function for autism populations.

Youth-Therapist and Parent-Therapist Match and Mismatch on Internalizing and Externalizing Treatment Goals as Predictors of Treatment Engagement.

Therapist-client cognitive match upon key constructs such as treatment goals is purported to be an important component of culturally competent care. For adolescent clients, treatment may involve both youths and their parents, suggesting the need to consider both youth-therapist and parent-therapist perspectives. This longitudinal study examined broadband youth-therapist and parent-therapist treatment goal matching and mismatching in relationship to treatment engagement in a culturally diverse sample of 245 outpatient mental health service-using youth. Although goal matching/mismatching did not uniformly predict treatment engagement as measured by a total score, youth-therapist internalizing goal matching predicted better youth engagement, and parent-therapist externalizing goal mismatch marginally predicted worse parent engagement. When selected post hoc analyses examined relationships to four individual engagement dimensions, youth-therapist internalizing goal matches positively predicted youth Client-therapist interaction, Communication/Openness, Client's perceived usefulness of therapy, and Collaboration with treatment, while parent-therapist externalizing goal mismatch negatively predicted parent Collaboration with treatment. Findings support the importance of cognitive match on treatment goals as well as the consideration of both parent and youth perspectives, matched and mismatched goals, internalizing and externalizing goals, and examining individual dimensions in addition to total scores of engagement.

Personalizing PCIT for culturally diverse families: Outcomes from a pilot trial utilizing the PersIn framework.

Culture-specific versions of evidence-based interventions are critically important to meeting the needs of underserved and minoritized populations but may also face significant barriers to large-scale implementation when there are settings with multiple cultural groups and within-group heterogeneity. The PersIn framework is a proposed approach for personalizing an evidence-based intervention to facilitate cultural responsiveness concurrent with fidelity to the original intervention, flexibility in individual implementation, and administration that is standardized, feasible, and replicable. This study describes pilot feasibility outcomes for MY PCIT (n = 32), a personalized version of Parent-Child Interaction Therapy for culturally diverse families that was developed as a proof-of-concept of the PersIn framework. This application of the PersIn framework was designed to enhance cultural responsiveness by increasing alignment between parent explanatory models and the presentation and delivery of PCIT. MY PCIT produced both statistically and clinically significant changes in pre-to post-treatment child outcomes and parent outcomes. Child behavior change outcomes were comparable to those reported by three benchmark studies, supporting the potential of this approach.

Examining English- and Spanish-Speaking Therapist Behaviors in Parent-Child Interaction Therapy.

Parent-child interaction therapy (PCIT) is a best-practice treatment for behavior problems in young children. In PCIT, therapists coach parents during in-vivo interactions to strengthen the parent-child relationship and teach parents effective ways of managing difficult child behaviors. Past research has found that different therapist coaching styles may be associated with faster skill acquisition and improved parent engagement. However, most research examining therapist behaviors has been conducted with English-speaking families, and there is limited research examining therapist behaviors when working with Spanish-speaking clients. In this study, English- and Spanish-speaking therapists' coaching behaviors (e.g., directive versus responsive) were examined, as well as their association with client outcomes, including speed of parental skill acquisition and treatment completion. Results suggested that coaching styles varied significantly between sessions conducted in Spanish versus English. In Spanish sessions, therapists had more total verbalizations than in English sessions and demonstrated higher rates of both total directive and responsive coaching. Responsive coaching was found to predict treatment completion across groups, while directive coaching was not. Directive and responsive coaching were not found to predict the rate of parental skill acquisition. Implications regarding the training of therapists and emphasizing cultural considerations are discussed.

Keeping an "I" on PRIDE: Measuring Imitation in Parent-Child Interaction Therapy.

In parent-child interaction therapy (PCIT), therapists encourage parents to imitate child behaviors in order to convey approval of the child's actions and promote the development of linguistic and social-cognitive skills. However, the Dyadic Parent-Child Interaction Coding System (DPICS-IV), used to measure skills taught during PCIT, does not include guidelines for coding parent-child imitation, making it difficult to determine how PCIT affects it. The current study addresses this problem by developing guidelines for coding imitation, which were then used to code DPICS-IV segments from 58 Mexican American families that participated in a past clinical trial. Results suggest that these coding guidelines can be used to reliably measure parent and child imitation. A series of additional analyses supported the construct validity of the codes. Specifically, there was a trend for parent imitation, but not child imitation, to increase more from pre-post treatment in PCIT relative to treatment as usual. In addition, parents who imitate their children were found to have children who imitate them more in return. Finally, improvement in parent imitation, but not child imitation, was significantly related to a decrease in child behavior problems. Further study is needed to determine the optimal frequency of imitation, and findings suggest that additional attention to coaching imitation may be warranted.

Personalizing Behavioral Parent Training Interventions to Improve Treatment Engagement and Outcomes for Culturally Diverse Families.

Behavioral Parent Training (BPT) interventions are efficacious for young children with externalizing behavior problems. However, not all families benefit, and ethnic minority families in particular are less likely to enroll, engage, and improve in BPT. Versions of BPT interventions tailored for specific ethnic groups have been successful at improving engagement and outcomes for ethnic minorities; however, the specificity of these models presents challenges for broad dissemination. This article presents a personalization approach (PersIn) that utilizes cultural assessment results to tailor treatment protocols to the characteristics of individual families. We believe this approach has the potential to maximize cultural sensitivity while preserving generalizability to both minority and non-minority ethnic groups. We further propose that personalization on Parent Explanatory Model (PEM) parameters that have been found to vary across ethnic groups and to impact treatment engagement and/or outcomes is a promising approach to decreasing disparities in BPTs. We describe examples of evidence-supported PEMs that present good targets for personalization and provide examples from MY PCIT to illustrate how PersIn can be applied to Parent-Child Interaction Therapy (PCIT).

Parent-child interaction therapy for Mexican Americans: a randomized clinical trial.

This study compared the effectiveness of a culturally modified version of Parent-Child Interaction Therapy (PCIT), called Guiando a Ninos Activos (GANA), to the effectiveness of standard PCIT and Treatment as Usual (TAU) for young Mexican Amerian children with behavior problems. Fifty-eight Mexican Amerian families whose 3- to 7-year-old child had a clinically significant behavior problems were randomly assigned to GANA, standard PCIT, or TAU. All three treatment approaches produced significant pre-post improvement in conduct problems across a wide variety of parent-report measures. GANA produced results that were significantly superior to TAU across a wide variety of both parent report and observational indices; however, GANA and PCIT did not differ significantly from one another. PCIT was superior to TAU on two of the parent report indices and almost all of the observational indices. There were no significant differences between the three groups on treatment dropout, and families were more satisfied with both GANA and PCIT than with TAU.

Household composition and maltreatment allegations in the US: Deconstructing the at-risk single mother family.

BACKGROUND: Previous research has demonstrated the association between child maltreatment and household composition, with increased maltreatment risk generally present in single mother households. However, existing research does not fully examine the complexity and configuration of single mother households. In particular, less is known about important variants of single parent family structures, such as grandparents residing in the home, and the extent to which household compositions change across time. OBJECTIVE: The present study examines rates of maltreatment allegations across various household compositions in a sample of single biological mother households. PARTICIPANTS AND SETTING: Youth participants (N = 417) were part of the larger multi-site Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) study. METHODS: Participants completed longitudinal assessments of household composition and maltreatment allegations from ages 4 to 10. RESULTS: The present study illustrates substantial variability in the rate of maltreatment allegations across different types of single mother household compositions. In particular, the presence of non-relatives, especially unrelated males, demonstrated an increased risk for maltreatment allegations in the home. Conversely, single mother homes with two or more adult relatives, especially grandmothers, were at reduced risk for child maltreatment allegations. CONCLUSIONS: This study highlights variability in maltreatment allegations among single mother homes, including how maltreatment allegations vary across different household configurations, across child age periods and across different risk levels.

Collectivism Is Associated With Greater Neurocognitive Fluency in Older Adults.

Neuropsychological research has been limited in the representation of cultural diversity due to various issues, raising questions regarding the applicability of findings to diverse populations. Nonetheless, culture-dependent differences in fundamental psychological processes have been demonstrated. One of the most basic of these, self-construal (individualism, collectivism), is central to how many other differences are interpreted. Self-construals may have possible consequences on social interactions, emotions, motivation, and cognition. This study aimed to evaluate the impact of self-construal on neurocognitive functions in older adults. A total of 86 community-dwelling older adults 60 years and older were assessed with three common self-report measures of self-construal along individualism and collectivism (IC). A cognitive battery was administered to assess verbal and non-verbal fluency abilities. Latent profile analysis (LPA) was used to categorize individuals according to IC, and one-way analyses of covariance (ANCOVA), including relevant covariates (e.g., ethnicity, gender, linguistic abilities), were used to compare neurocognitive functions between individualists and collectivists. Collectivists outperformed individualists on left frontally-mediated measures of verbal fluency (action, phonemic) after controlling for relevant covariates, F (1,77) = 6.942, p = 0.010, η 2 = 0.061. Groups did not differ on semantic fluency, non-verbal fluency, or attention/working memory (all ps > 0.05). These findings suggest a cognitive advantage in collectivists for verbal processing speed with an additional contribution of left frontal processes involved in lexicosemantic retrieval. Self-construal may provide a meaningful descriptor for diverse samples in neuropsychological research and may help explain other cross-cultural differences.

An Exploration of Parent-Youth Agreement on Functional Impairment in Adolescents Utilizing Outpatient Mental Health Services.

Parent-youth agreement on the youth's functional impairment may have important implications for mental health service utilization, assessment, therapy goal development, and treatment engagement for adolescents. The present study examines parent-youth agreement on their perceptions of youth functional impairment in a predominantly racial/ethnic minority sample of adolescents utilizing outpatient mental health services. Parent and youth functional impairment ratings were compared, and agreement was estimated in multiple ways. On average, parents indicated higher levels of youth functional impairment compared to youth in their overall scores, and when differences existed between parents and youth at the functioning domain and item level. Although there was similarity in the proportion of parents and youth who reported total impairment above the clinical cut-off, actual agreement between parent-youth pairs was only slight. There appeared to be substantial variation in agreement levels when identifying problems in functional impairment at the domain and item levels, and some areas of strong consensus were identified. These findings highlight the need to consider parent-youth agreement in perceptions of functional impairment and the complexities that may underlie this agreement.

Racial variation in self-labeled child abuse and associated internalizing symptoms among adolescents who are high risk.

One thousand and ten Non-Hispanic White, African American, Hispanic, and Asian Pacific Islander youth who were high risk and receiving public sector services were interviewed regarding history of child emotional and physical abuse and current internalizing symptoms. The study examined whether race moderated the association between adolescents' reports of specific parent behaviors and their self-labeling as victims of abuse. The study also examined whether reports of parental behaviors or self-labeled abuse better predicted internalizing symptoms, and whether these associations differed by race. When reporting punitive parent behavior, Non-Hispanic White youth were more likely to describe themselves as abused compared to Asian Pacific Islanders. Reported punitive parental behaviors accounted for more variance in internalizing symptoms than did self-labeled abuse. Reports of parent behaviors were more strongly related to concurrent internalizing symptoms among ethnic minority youth than among Non-Hispanic White youth. Results are discussed in the context of cultural competence in identification of child abuse.

Self-Reported Parenting of Clinic-Referred and Non-referred Mexican American Mothers of Young Children.

Behavioral parent training (BPT) interventions for child behavior problems have been based on decades of research that demonstrate links between particular parent behaviors and child externalizing problems. However, the majority of this research has been conducted with European-American (EA) families, and less is known about whether these findings can be generalized to Mexican Americans (MAs). In the current study, we investigated self-reported parenting practices that have been associated with externalizing behavior problems among EA families (harsh parenting, inconsistency, and low parental warmth), to determine if those practices can also differentiate MA mothers whose young children have clinically significant behavior problems from MA mothers whose children do not have behavior problems. Participants were 115 MA families with young children, 58 with a child with clinically significant behavior problems and 57 with a child in the normal range for such problems. Results indicated that MA mothers whose children have behavior problems self-reported significantly less warmth and consistency and more harsh parenting compared to parents whose children's behavior was in the normal range. These findings indicate that parenting behaviors that are associated with externalizing behavior problems among EA families are associated with the same problems among MA families with young children, suggesting that parent training interventions designed to target these behaviors are also likely to be relevant to MA families with children in this age range. However, findings also indicate that parenting behaviors differ depending on acculturation level, suggesting that BPT programs must respond to variation in normative parenting practices for MA families.

Racial and ethnic differences in utilization of mental health services among high-risk youths.

OBJECTIVE: Racial and ethnic disparities in mental health service use have been identified as a major public health problem. However, the extent to which these disparities may be accounted for by other confounding sociodemographic or clinical predictors of service use (e.g., family income, functional impairment, caregiver strain) is relatively unexplored, especially for youth services. The goal of this study was to test for racial/ethnic disparities in use of a variety of outpatient, inpatient, and informal mental health services among high-risk youths, with the effects of other predictive factors controlled. METHOD: Participants were 1,256 youths ages 6-18 years who received services in a large, publicly funded system of care (including the child welfare, juvenile justice, special education, alcohol and drug abuse, and mental health service sectors). Youths and caregivers were interviewed with established measures of mental health service use, psychiatric diagnoses, functional impairment, caregiver strain, and parental depression. RESULTS: Significant racial/ethnic group differences in likelihood of receiving any mental health service and, specifically, formal outpatient services were found after the effects of potentially confounding variables were controlled. Race/ethnicity did not exert a significant effect on the use of informal or 24-hour-care services. CONCLUSIONS: Racial/ethnic disparities in service use remain a public health problem.

Why bother with beliefs? Examining relationships between race/ethnicity, parental beliefs about causes of child problems, and mental health service use.

In this study, the authors examined the role of parental beliefs about the causes of child problems in predicting later mental health service use in a large, diverse population of at-risk youths. Study hypotheses were that parental beliefs consistent with biopsychosocial causes would be associated with later mental health service use; sociological, spiritual, or nature disharmony etiologies would be negatively associated with service use; and beliefs would partially mediate the relationship between race/ethnicity and service use. Of the 5 biopsychosocial beliefs, 2 were positively related to later mental health service use. Unexpectedly, of the 6 parental beliefs related to sociological, spiritual, or nature disharmony etiologies, only 1 was negatively associated with later service use patterns. Parental endorsement of etiologies relating to physical causes, relational issues, trauma, and prejudice was found to partially mediate the relationship between race/ethnicity and service use for Asian/Pacific Islander American and Latino youths. ((c) 2005 APA, all rights reserved).

The acculturation gap-distress hypothesis among high-risk Mexican American families.

The authors tested the acculturation gap-distress hypothesis by examining whether parent-adolescent acculturation gaps were associated with greater conflict and youth conduct problems among 260 high-risk Mexican American families. The authors operationalized acculturation gaps in 2 ways: parent-youth mismatches in acculturation style, and parent-youth discrepancies in acculturation toward both mainstream and heritage cultures. Acculturation gaps were common, but results of hierarchical regression analyses indicated that parent-youth discrepancies in acculturation toward mainstream and heritage cultures were not related to increased conflict or youth conduct problems. Conduct problems were no higher in families in which the adolescent was more aligned with mainstream culture than the parent. Unexpectedly, the authors found more youth conduct problems in families in which the youth was more aligned with traditional culture than the parent. The results call into question the assumption that the more rapid acculturation of adolescents to American culture inevitably leads to distress in minority families.