Addressing Barriers to Recruitment and Retention in the Implementation of Parenting Programs: Lessons Learned for Effective Program Delivery in Rural and Urban Areas.

Research has demonstrated the effectiveness of family-based programs for reducing adolescent risk behaviors and promoting adolescent health; however, parent engagement, specifically in terms of recruitment and retention, remains a consistent challenge. Recruitment rates for family-based prevention programs range from 3 to 35%, while, on average, 28% of caregivers drop out before program completion. Thus, engagement of parents in prevention programming is of utmost concern to ensure families and youth benefit from implementation of family-based programs. In this manuscript, two Centers for Disease Control and Prevention-funded projects share their experiences with engagement of parents in violence prevention programs. Problems related to parent engagement are reviewed, as are structural, attitudinal, and interpersonal barriers specific to recruitment and retention. Examples of successful implementation strategies identified across urban and rural sites are also analyzed and lessons learned are provided.

Parenting Wisely Six Months Later: How Implementation Delivery Impacts Program Effects at Follow-Up.

We evaluated the effectiveness of the Parenting Wisely (PW) program 6 months post intervention and assessed differences based on delivery format. Using a quasi-experimental design, parents (N = 311) participated in the PW program in one of five formats (i.e., parents-only intensive workshop, parents-only 5-week group, parents and adolescents 5-week group, parent and adolescent online, and parent-only online format). An additional 53 parents served as a comparison group. We used the McMaster Family Assessment Device, the Child Behavior Checklist, and the Violent Behavior Checklist to measure family functioning, parenting, and adolescent behavior. Relative to the comparison group, at 6 month follow-up parents who participated in PW reported increases in confidence in their parenting skills, decreases in conflicts with their adolescents, and decreases in adolescent externalizing and violent behavior. Mechanisms of change analyses supported the conceptual model that program effects were related to child behavior changes by influencing positive parenting and decreasing negative family dynamics. PW effectiveness did not vary substantially by delivery format, except for the intensive workshop format, which was less effective than other formats. These findings extend research on PW to include evidence of sustained program effects on adolescent externalizing and violent behaviors in an ethnically diverse, socioeconomically disadvantaged sample. Study findings are relevant to agencies and clinicians who are seeking to implement an evidence-based, flexible parent-training program.

Risk and protective factors across multiple microsystems associated with internalizing symptoms and aggressive behavior in rural adolescents: Modeling longitudinal trajectories from the Rural Adaptation Project.

The current study examined risk and protective factors across microsystems that impact the development of internalizing symptoms and aggression over 4 years in a sample of culturally diverse, rural adolescents. We explored whether risk and protective factors across microsystems were associated with changes in rates of internalizing symptoms and aggressive behavior. Data came from the Rural Adaptation Project (RAP), a 5-year longitudinal panel study of more than 4,000 students from 26 public middle schools and 12 public high schools. Three level HLM models were estimated to predict internalizing symptoms (e.g., depression, anxiety) and aggression. Compared with other students, risk for internalizing symptoms and aggression was elevated for youth exposed to risk factors in the form of school hassles, parent-child conflict, peer rejection, and delinquent friends. Microsystem protective factors in the form of ethnic identity, religious orientation, and school satisfaction decreased risk for aggression, but were not associated with internalizing symptoms, whereas future orientation and parent support decreased risk for internalizing symptoms, but not aggression. Results indicate that risks for internalizing symptoms and aggression are similar, but that unique protective factors are related to these adolescent behavioral health outcomes. Implications and limitations were discussed. (PsycINFO Database Record

Family dynamics and aggressive behavior in Latino adolescents.

OBJECTIVES: Despite high prevalence rates and evidence that acculturation is associated with adolescent behavioral and mental health in Latino youth, little research has focused on aggressive behavior for this population. The aim of the current study was to fill this research gap by examining the influence of several aspects of family functioning, including parent-adolescent conflict, parent worry, and parent marital adjustment, on aggression among Latino adolescents. METHOD: Data come from the Latino Acculturation and Health Project (LAHP), a longitudinal investigation of acculturation in Latino families in North Carolina and Arizona. Hierarchical linear modeling was used to estimate a longitudinal rater effects model of adolescent aggression as reported by 258 Latino adolescents each paired with 1 parent for a total of 516 participants across 4 time points over a span of 18 months. RESULTS: Results indicated a general decline in aggression over the study window. In addition, parent-adolescent conflict and parent worry predicted higher adolescent aggression whereas parent marital adjustment predicted lower adolescent aggression. CONCLUSIONS: The salience of family risk factors for aggression among Latino adolescents is discussed. (PsycINFO Database Record

Constructing "Packages" of Evidence-Based Programs to Prevent Youth Violence: Processes and Illustrative Examples From the CDC's Youth Violence Prevention Centers.

This paper describes the strategic efforts of six National Centers of Excellence in Youth Violence Prevention (YVPC), funded by the U.S. Centers for Disease Control and Prevention, to work in partnership with local communities to create comprehensive evidence-based program packages to prevent youth violence. Key components of a comprehensive evidence-based approach are defined and examples are provided from a variety of community settings (rural and urban) across the nation that illustrate attempts to respond to the unique needs of the communities while maintaining a focus on evidence-based programming and practices. At each YVPC site, the process of selecting prevention and intervention programs addressed the following factors: (1) community capacity, (2) researcher and community roles in selecting programs, (3) use of data in decision-making related to program selection, and (4) reach, resources, and dosage. We describe systemic barriers to these efforts, lessons learned, and opportunities for policy and practice. Although adopting an evidence-based comprehensive approach requires significant upfront resources and investment, it offers great potential for preventing youth violence and promoting the successful development of children, families and communities.

Community Engagement in Youth Violence Prevention: Crafting Methods to Context.

The purpose of the Youth Violence Prevention Centers (YVPC) Program at the Centers for Disease Control and Prevention is to reduce youth violence in defined high-risk communities through the implementation and evaluation of comprehensive, evidence based prevention strategies. Within this common framework, each YVPC varies in its structure and methods, however all engage communities in multiple ways. We explore aspects of community engagement employed by three centers that operate in very different contexts: a rural county in North Carolina; a suburban area of Denver, Colorado; and an urban setting in Flint, Michigan. While previous research has addressed theories supporting community involvement in youth violence prevention, there has been less attention to the implementation challenges of achieving and sustaining participation. In three case examples, we describe the foci and methods for community engagement in diverse YVPC sites and detail the barriers and facilitating factors that have influenced implementation. Just as intervention programs may need to be adapted in order to meet the needs of specific populations, methods of community engagement must be tailored to the context in which they occur. We discuss case examples of community engagement in areas with varying geographies, histories, and racial and ethnic compositions. Each setting presents distinct challenges and opportunities for conducting collaborative violence prevention initiatives and for adapting engagement methods to diverse communities. Although approaches may vary depending upon local contexts, there are certain principles that appear to be common across cultures and geography: trust, transparency, communication, commitment. We also discuss the importance of flexibility in community engagement efforts.

Evaluating dosage effects for the positive action program: How implementation impacts internalizing symptoms, aggression, school hassles, and self-esteem.

Positive Action (PA) is a school-based intervention for elementary-, middle-, and high-school students that aims to decrease problem behaviors (e.g., violence, substance use) and increase positive behaviors (e.g., academic achievement, school engagement). PA has a long history of documented success achieving these aims, making it an Evidence Based Practice (EBP). Intervention research on EBP's has established the importance of implementation fidelity, especially with regard to program dosage; failure to properly implement an EBP can have negative consequences on targeted outcomes, especially if participants are exposed to a low dosage of the program (e.g., fewer lessons than specified). Much of the current research on PA has neglected to examine how program dosage impacts PA's effect on targeted outcomes. Using propensity score models, multiple imputation, and a 2-level hierarchical linear model, the current study fills this gap and examines how different dosages of PA as measured by years participating in PA and number of PA lessons, impacts adolescent internalizing symptoms, aggression, perceptions of school hassles, and self-esteem over a 3-year period. The current sample included middle school students in grades 6, 7, and 8 (N = 5,894). The findings indicate that students who received 3 years of the PA intervention and a high number of PA lessons had a significantly higher self-esteem score than those who received 0 years of PA or zero lessons. Participants who received 1 year of PA also reported significantly lower school hassle scores than those who received 0 years. Dosage had no statistically significant effects on aggression or internalizing score. Implications are discussed. (PsycINFO Database Record

A Longitudinal Evaluation of the Positive Action Program in a Low-Income, Racially Diverse, Rural County: Effects on Self-Esteem, School Hassles, Aggression, and Internalizing Symptoms.

Positive Action is a school-based program that aims to decrease problem behaviors (e.g., violence, substance use) and increase positive behaviors (e.g., school engagement, academic achievement). Although a number of studies have shown that Positive Action successfully achieves these goals, few studies have evaluated the program's effectiveness in rural schools. Given that rural youth are at an increased risk for risky behaviors (e.g., violence, substance use), this is a critical gap in the existing Positive Action research base. The current study assesses the impact of Positive Action on change rates of self-esteem, school hassles, aggression, and internalizing symptoms in a group (N = 1246, 52% female) of ethnically/racially diverse (27% White, 23% African American, 12% mixed race/other, 8% Latino, 30% as American Indian) middle school youth (age range 9-20) located in two violent, low-income rural counties in North Carolina. One county engaged in Positive Action over the 3-year study window while the other county did not. Following multiple imputation and propensity score analysis, 4 two-level hierarchical linear models were run using each of the outcome measures as dependent variables. The results indicate that the program generates statistically significant beneficial effects for youth from the intervention county on self-esteem scores and school hassles scores. Although the program generates beneficial effects for intervention youth on the change in aggression scores, the finding is not statistically significant. The finding on the change in internalizing scores shows a non-significant detrimental effect: the youth from the comparison county have lower internalizing scores than those from the intervention county. Implications are discussed.

The effects of positive and negative parenting practices on adolescent mental health outcomes in a multicultural sample of rural youth.

The quality of parent-child relationships has a significant impact on adolescent developmental outcomes, especially mental health. Given the lack of research on rural adolescent mental health in general and rural parent-child relationships in particular, the current longitudinal study explores how rural adolescents' (N = 2,617) perceptions of parenting practices effect their mental health (i.e., anxiety, depression, aggression, self-esteem, future optimism, and school satisfaction) over a 1 year period. Regression models showed that current parenting practices (i.e., in Year 2) were strongly associated with current adolescent mental health outcomes. Negative current parenting, manifesting in parent-adolescent conflict, was related to higher adolescent anxiety, depression, and aggression and lower self-esteem, and school satisfaction. Past parent-adolescent conflict (i.e., in Year 1) also positively predicted adolescent aggression in the present. Current positive parenting (i.e., parent support, parent-child future orientation, and parent education support) was significantly associated with less depression and higher self-esteem, future optimism, and school satisfaction. Past parent education support was also related to current adolescent future optimism. Implications for practice and limitations were discussed.

Familial influences on internalizing symptomatology in Latino adolescents: an ecological analysis of parent mental health and acculturation dynamics.

The aim of this study was to examine if family system dynamics (e.g., parent mental health, marriage quality, conflict, and cohesion) that have often been overlooked when studying Latino families play a more important role in predicting adolescent internalizing symptoms than acculturation processes. Data comes from the Latino Acculturation and Health Project, a longitudinal investigation of acculturation in Latino families in North Carolina and Arizona (Smokowski & Bacallao, 2006, 2010). Researchers conducted in-depth, community-based interviews with 258 Latino adolescents and 258 of their parents in metropolitan, small-town, and rural areas. Interviews were conducted at four time points at intervals of approximately 6 months. Parent and adolescent ratings of the adolescent's internalizing symptoms were used as the dependent variable in a longitudinal hierarchical linear model with a rater effects structure. Results showed that parent-adolescent conflict and parent mental health (fear/avoidance of social situations and humiliation sensitivity) were significant predictors of adolescent internalizing symptoms. Acculturation scales were not significant predictors; however, internalizing symptoms decreased with time spent in the United States. Females and adolescents from lower socioeconomic status families reported more internalizing symptoms, while participants who had been in the United States longer reported fewer internalizing symptoms. Implications were discussed.

Multilevel risk factors and developmental assets for internalizing symptoms and self-esteem in disadvantaged adolescents: modeling longitudinal trajectories from the Rural Adaptation Project.

The current study filled significant gaps in our knowledge of developmental psychopathology by examining the influence of multilevel risk factors and developmental assets on longitudinal trajectories of internalizing symptoms and self-esteem in an exceptionally culturally diverse sample of rural adolescents. Integrating ecological and social capital theories, we explored if positive microsystem transactions are associated with self-esteem while negative microsystem transactions increase the chances of internalizing problems. Data came from the Rural Adaptation Project, a 5-year longitudinal panel study of more than 4,000 middle school students from 28 public schools in two rural, disadvantaged counties in North Carolina. Three-level hierarchical linear modeling models were estimated to predict internalizing symptoms (e.g., depression, anxiety) and self-esteem. Relative to other students, risk for internalizing problems and low self-esteem was elevated for aggressive adolescents, students who were hassled or bullied at school, and those who were rejected by peers or in conflict with their parents. Internalizing problems were also more common among adolescents from socioeconomically disadvantaged families and neighborhoods, among those in schools with more suspensions, in students who reported being pressured by peers, and in youth who required more teacher support. It is likely that these experiences left adolescents disengaged from developing social capital from ecological microsystems (e.g., family, school, peers). On the positive side, support from parents and friends and optimism about the future were key assets associated with lower internalizing symptoms and higher self-esteem. Self-esteem was also positively related to religious orientation, school satisfaction, and future optimism. These variables show active engagement with ecological microsystems. The implications and limitations were discussed.

Obstacles to getting ahead: how assimilation mechanisms impact undocumented mexican immigrant families.

This study explores the roles played by U.S. schools, workplaces, churches, and peers in the acculturation process of immigrant adolescents. Qualitative interviews were conducted with members of 10 undocumented Mexican families (12 adolescents and 14 of their parents) who had immigrated within the past 7 years. Results indicated that assimilation was prompted by two powerful mechanisms: monolingualism and discrimination. Monolingualism and discrimination in interpersonal interactions and social policies directed Mexican adolescents and their parents to learn English and to conform to host culture norms, appearance, and behaviors to advance in school and in their work. These assimilation mechanisms contributed to female adolescents' and parents' feelings of anxiety and depression. Male adolescents reported feeling angry and ready to physically defend themselves. Mexican families found a refuge from assimilation stress in church. Churches valued biculturalism and religious faith was used to handle daily assimilation stress. Implications for social policy were discussed.

Influence of risk factors and cultural assets on Latino adolescents' trajectories of self-esteem and internalizing symptoms.

In this study, we examined longitudinal, person-centered trajectories of acculturation, internalizing symptoms, and self-esteem in 349 Latino adolescents. We compared acculturation measures (time in the US, culture-of-origin involvement, US cultural involvement, for both parents and adolescents); acculturation stressors (perceived discrimination, acculturation conflicts); and family dynamics (parent-adolescent conflict, familism). Results indicated that, over time, Latino adolescents' internalizing problems decreased and their self-esteem increased. However, we showed that increased length of time living in the US was significantly related to lower self-esteem among adolescents. Parent-adolescent conflict was a strong risk factor, which not only directly heightened internalizing symptoms and lowered self-esteem, but also mediated the effects of acculturation conflicts and perceived discrimination on these outcomes. Our findings revealed familism as a cultural asset associated with fewer internalizing symptoms and higher self-esteem. Internalizing symptoms were also minimized by the adolescent's involvement in the US culture whereas bicultural adolescents with high culture-of-origin involvement reported higher self-esteem. We discussed the limitations and implications of this study for future research and practice.

Acculturation and aggression in Latino adolescents: modeling longitudinal trajectories from the Latino Acculturation and Health Project.

This study examines how multiple indicators of adolescent and parent acculturation relate to longitudinal trajectories of Latino adolescent aggression. The hierarchical linear modeling analysis is based on a final sample of 256 adolescents paired with one parent. Of the adolescents, 66% were born outside of the United States and the remaining 34% were US-born. Families lived in two sites: 38% lived in North Carolina and 62% lived in Arizona. The overall trajectory of Latino adolescent aggression displays a statistically significant negative trend best characterized by a quadratic curve. We delineate significant risk factors related to aggression levels, and show that gender, age, parent-reported acculturation conflicts, and adolescent-reported parent-adolescent conflicts are associated with higher levels of adolescent aggression. We discuss the study limitations, implications of the findings, and fertile ground for future research.

Acculturation and adjustment in Latino adolescents: how cultural risk factors and assets influence multiple domains of adolescent mental health.

The purpose of this study was to examine the relationships among risk factors, cultural assets, and Latino adolescent mental health outcomes. We extend past research by using a longitudinal design and evaluating direct and moderated acculturation effects across a range of internalizing, externalizing, and academic engagement outcomes. The sample consisted of 281 Latino/a youths and one of their parents in metropolitan, small town, and rural areas within North Carolina and Arizona. The length of time the adolescent was in the U.S. was positively related to humiliation, aggression, and school bonding. Adolescent U.S. cultural involvement and parent culture of origin involvement were not significantly related to adolescent mental health or school bonding. Parent U.S. involvement had an inverse association with adolescent social problems, aggression, and anxiety. Adolescent culture of origin involvement was positively related to adolescent self-esteem 1 year later. Inverse relationships were found for the link between adolescent culture of origin involvement and hopelessness, social problems, and aggression 1 year later. Implications for prevention programming and policy development are discussed.

Entre dos mundos/between two worlds: bicultural development in context.

How do Mexican immigrant adolescents balance different, and often oppositional, cultural influences in the acculturation process? In this article, we explore how acculturating adolescents absorb cultural messages and go about creating their (multiple) identities. Guided by Alternation Theory, in-depth qualitative interviews were conducted with 12 undocumented Mexican adolescents and 14 of their parents who had immigrated to North Carolina within the past 7 years. All of the families had adolescent children who were born in Mexico. At least one parent and one adolescent from each family were interviewed. Interviewing multiple family members allowed us to examine how bicultural development progressed differently for various family members, and how the whole family balanced between cultural systems. Mexican parents and adolescents were acculturating while trying to resist assimilation pressures. They maintained strong Mexican identities that were preserved by practicing Mexican customs, values, and traditions in their homes and churches. Meeting U.S. cultural and linguistic demands at work and in school placed Mexican parents and adolescents between the two cultural systems. This prompted adolescents and parents to integrate some U.S. customs, language, or social behaviors into their daily lives, increasing bilingualism and, in some cases, biculturalism.

Acculturation, internalizing mental health symptoms, and self-esteem: cultural experiences of Latino adolescents in North Carolina.

This investigation examined acculturation risk factors and cultural assets, internalizing behavioral problems, and self-esteem in 323 Latino adolescents living in North Carolina. Multiple regression analyses revealed two risk factors-perceived discrimination and parent-adolescent conflict-as highly significant predictors of adolescent internalizing problems and low self-esteem. Adolescents who were highly involved in Latino culture and who experienced high parent-adolescent conflict were found particularly at risk for internalizing problems. Biculturalism and familism were cultural assets found associated with fewer internalizing problems and higher self-esteem. For internalizing problems, familism's protective effect was mediated by parent-adolescent conflict. Implications were discussed.

Acculturation and aggression in Latino adolescents: a structural model focusing on cultural risk factors and assets.

The specific aim of this investigation was to map cultural factors associated with aggressive behavior in Latino adolescents. Interviews were conducted with a sample of 481 foreign- and U.S.-born Latino adolescents living in North Carolina and Arizona. Structural Equation Modeling was used to validate a conceptual model linking adolescent and parent culture-of-origin and U.S. cultural involvement, acculturation conflicts, and perceived discrimination to family processes (familism and parent-adolescent conflict) and adolescent aggression. Parent-adolescent conflict was the strongest cultural risk factor followed by perceived discrimination. Familism and adolescent culture-of-origin involvement were key cultural assets associated with less aggressive behavior. Exploratory mediation analyses suggested that familism and parent-adolescent conflict mediated the effects of acculturation conflicts, parent and adolescent culture-of-origin involvement, and parent U.S. cultural involvement on adolescent aggression. Implications for prevention programming were discussed.

"Entre dos mundos" (Between Two Worlds): bicultural skills training with Latino immigrant families.

This paper focuses on the acculturation model of second-culture-acquisition for Latino immigrants. Two theoretical frameworks, assimilation and alternation theories, are compared within the acculturation model. Empirical research findings suggest that assimilation is a risk factor for increases in negative health behaviors and mental health problems. Conversely, biculturalism appears to be an emerging protective factor that buffers assimilation stress, enhances socio-cognitive functioning, and increases academic achievement. A review of bicultural skills training interventions shows these programs are effective in decreasing the risk for problematic behavior. Finally, a refined model of bicultural skills training for Latino immigrant families is proposed based on the acculturation research literature and extensive interviews with Latino families in North Carolina.