Parent-Child Interaction Therapy for Latinx and non-Latinx Families: A Comparison of Barriers, Treatment Attitudes, and Behavioral Outcomes

Amy Hendricks1, Ayla R. Mapes, M.A.1, Lauren B. Quetch, Ph.D.1, Emma Girard, Psy.D.2,3, and Cheryl B. McNeil, Ph.D.4

1University of Arkansas

2University of California Riverside, School of Medicine

3Riverside University Health System - Behavioral Health: Preschool 0-5 Programs, Riverside, California

4West Virginia University

Abstract

Parent-Child Interaction Therapy (PCIT) is an evidence-based parenting intervention for children with disruptive behavior problems. While PCIT has shown strong evidence for reducing disruptive behaviors and enhancing parent-child relationships, the model would benefit from greater explorations with diverse and historically marginalized families. The current study examined the effectiveness of PCIT and barriers to treatment participation. Participants were 83 families receiving PCIT. Participants were primarily Latinx from a community in Riverside, California. The study utilized a longitudinal design (pre, mid, post), with information collected on treatment barriers, treatment attitudes, behavioral outcomes, graduation rates, and number of sessions attended. Results indicated there were no significant different between Latinx and non-Latinx families on reported barriers or attitudes. There was low endorsement of cost and stress barriers and most families rated positive attitudes regarding comfort with their therapist’s ethnicity and acceptance of treatment skills within their community. Disruptive behavioral scores significantly decreased across both ethnic groups, and this relationship was not moderated by therapy attitudes. Finally, graduation rates and the average number of sessions attended did not significantly differ across ethnic groups. Overall, results suggest PCIT had similar reductions for disruptive behaviors for Latinx and non-Latinx families, and that treatment was viewed favorably. Future research should expand on the effectiveness of PCIT for diverse communities and examine other barriers to treatment, especially for Latinx communities.

Keywords: parent-child interaction therapy, disruptive behavior, Latinx families, barriers, treatment completion

Parent-Child Interaction Therapy for Latinx and non-Latinx Families: A Comparison of Barriers, Treatment Attitudes, and Behavioral Outcomes

There is a growing trend in psychological practice to implement evidence-based treatments (EBTs; Barrera et al., 2011); EBTs are treatments that have been scientifically shown to improve client outcomes in terms of symptoms, functional status, and quality of life as compared to alternative treatment models (Drake et al., 2001). However, concerns exist regarding the effectiveness of EBTs with culturally diverse clients (Sue et al., 2009). Treatment efficacy and effectiveness studies frequently neglect the recruitment and enrollment of marginalized groups such as Latinx, non-White populations, and fail to retain these families at a high rate compared to White, non-Latinx individuals (Cunningham et al., 2000; Miranda et al., 2005). This lack of representation in empirical work makes it difficult to determine if the current delivery of EBTs (often constructed for and normed on White, non-Latinx samples) in community mental health settings are effective, have no effects, or are even harmful for Latinx populations (Miranda et al., 2005). Through research, a better understanding is possible of how these populations respond to EBT delivery and why they are less likely to access services.

Parent-Child Interaction Therapy

            One effective, largely studied EBT for young children (2-7 years) and their families is Parent-Child Interaction Therapy (PCIT). PCIT is an evidence-based intervention developed for addressing child disruptive behavior problems by building stronger parent-child relationships and establishing clear and consistent discipline techniques (McNeil & Hembree-Kigin, 2010). PCIT is composed of two phases: (1) Child-Directed Interaction (CDI; a nurturing phase where parents let children lead the interaction while building positive parenting strategies) and (2) Parent-Directed Interaction (PDI; a discipline phase where parents lead the interaction while learning consistent discipline procedures). Unlike other parent training treatments, a PCIT therapist views the parent-child interaction through a one-way mirror, coaching and providing immediate feedback to parents as they learn to attend positively, consistently, and predictably to the child’s prosocial behaviors while ignoring or addressing negative behaviors. PCIT is designed to break the parent-child coercive cycle by teaching parents to reinforce children’s prosocial behaviors while also helping children gain healthy emotion regulation skills (Lieneman et al., 2020; Patterson 1982). In empirical studies, PCIT has been shown to increase both positive parenting skills and child compliance rates while reducing levels of parenting stress and child behavioral problems (Abrahamse et al., 2012; Schuhmann et al., 1998). Studies indicate impressive success rates of around 80 percent for PCIT (Eyberg et al., 2001; Gallagher, 2003). Moreover, this reduction in child behavior problems and increase in positive parenting skills has even been shown to be maintained 6 years after treatment (Hood & Eyberg, 2003).

            While there are significant empirical findings documenting the positive outcomes associated with engagement in PCIT for White families (e.g., Brinkmeyer & Eyberg, 2003), few studies have examined the effectiveness of PCIT for Latinx families (McCabe & Yeh, 2009; McCabe et al., 2010; McCabe et al., 2012; Ramos et al., 2017; Thomas et al., 2017). This lack of research on Latinx families is concerning. Given what is known about the unique needs of Latinx families and their concerns surrounding family-focused treatments, it is imperative that further research explores the effectiveness of PCIT for this population. Additionally, it is important to explore what Latinx families may like about the structure of PCIT as well as reasons why they may terminate from treatment to determine ways to improve the current PCIT model.

Cultural Considerations

Culture is an important factor in shaping individual beliefs and expectations for behavioral health treatment. For example, researchers have found Latinx families prefer family systems change approach because of an emphasis on interconnection, reciprocity, and filial responsibility (Kumpfer et al., 2002). Latinx families tend to practice parenting influenced by respeto (respect) and familismo (familism) culture. In respeto culture, children display respect for authority figures such as caregivers and teachers. Parents who highly value respeto culture may feel less comfortable with the child-led interaction component of PCIT and may be more inclined towards a strict discipline style, leading them to feel that punishments such as ignoring a child’s behavior problems and instituting time outs are too mild (McCabe et al., 2005). In familismo culture, families have strong bonds. Familismo is a source of support but can also be a source of stress; for example, grandparents may provide assistance with raising their grandchildren but may also be critical of the practices used by parents (McCabe et al., 2005). Latinx families also practice personalismo (personalism), which is the desire to form close personal bonds, meaning that Latinx parents are more likely to want to form a close relationship with the therapist (Matos et al., 2006). Moreover, Latinx parents desire interventions that promote group cohesion and supportive relationships (Parra-Cardona et al., 2009).

Another factor affecting parenting and parent-child relationships in Latinx immigrant families is acculturation. Acculturation is the dual process of cultural and psychological change that takes place as a result of contact between two or more cultural groups and their individual members (Berry, 2015). This often occurs when individuals or families move to a new country, and the process involves adopting the language, attitudes, culture, and behaviors of the new host country (Zane & Mak, 2003). While individuals experience changes in behavior through long-term psychological processes (Berry, 2015), families moving to new countries may experience different levels of acculturation among family members. Portes and Rumbaut (1996) proposed ideas of “generational consonance” (when the level of acculturation is similar for parents and children) and “generational dissonance” (when the level of acculturation is dissimilar). Generational dissonance has been linked with more frequent and more intense family conflict (Farver et al., 2002). It has also been identified as a risk factor for declines in the quality of the parent-child relationship (Birman, 2006). In fact, one study found that a high level of discrepancy in American attitude orientation between fathers and children was associated with unsupportive parenting practices (Kim et al., 2009). Often, level of acculturation is associated with language preference and may be why Spanish-speaking families are more influenced by respeto cultural values (Ramos et al., 2017). Acculturation may impact how or why Latinx families seek mental health services in several ways; a) Latinx families with a high level of generational dissonance may experience more intense family conflict, leading them to seek services for these issues, or b) Latinx families who are highly acculturated may be more likely to seek services because less importance is placed on familismo cultural values (desire to keep problems within the family). Acculturation can play an essential part in the relationship between immigrant parents and children and should be considered by the therapist. 

Cultural values are likely linked with primary language, with Spanish-speaking Latinx families being more strongly influenced by respeto cultural values (Ramos et al., 2017). In fact, research on one family intervention that was culturally adapted for Latinx families (with a focus on respect for family traditions) resulted in an increased completion rate from 65% of enrolled families to an impressive 98% after 5 years of implementation (Kumpfer et al., 2002). Latinx families have also stressed the importance therapists being respectful and collaborative toward Latinx cultural values while implementing parenting interventions (Parra-Cardona et al., 2009). For example, Latinx families with strong personalismo culture may require more rapport building. When working with Latinx families, therapists should consider cultural values such as respeto, familismo, and personalismo and how they influence Latinx families’ attitudes regarding therapy.

Just as Spanish-speaking in Latinx families can influence the presence of respeto cultural values and how families view mental health treatment, so too does the absence of English (i.e., Limited English Proficiency; LEP) which can impact individuals’ access to mental health treatment in the United States. Lower English proficiency is associated with a lower likelihood of seeking or acquiring mental health care, longer durations for untreated psychological disorders, higher likelihood of being uninsured, and lower education level (Bauer et al, 2010; Kim et al., 2011). A reason for this may be that low health literacy is more prevalent among those with LEP; Sentell and Braun (2012) found that those with LEP reported low health literacy at a greater rate (44.9%) than English-speakers (13.8%). Language barriers may be especially important in mental health care settings as mental health treatment relies on direct verbal communication rather than objective tests for physical illness (Sentell et al., 2007). Indeed, LEP was found to significantly decrease the odds of mental health service use among Latinx immigrants (Kim et al., 2011).

While factors such as acculturation and familismo were not directly assessed in the current study, these cultural considerations are important contextual pieces to be considered when examining the parent-child relationship for Latinx families. Awareness of these cultural considerations can improve the acceptability of the treatment for Latinx families and can be a way to help clinicians improve their cultural sensitivity. There have been efforts to incorporate Latinx cultural values into PCIT, most notably by McCabe and colleagues whose version of PCIT included increased collaboration and rapport building with parents, framing the program as an educational intervention rather than as a mental health treatment (to reduce stigma), as well as increased cultural training for clinicians (McCabe et al., 2005; 2010). It was found that there were no significant differences in child behavior outcomes between the modified version of PCIT (called GANA or Guiando a Niños Activos) and PCIT, although GANA did outperform PCIT on parent report measures and CBCL Internalizing (McCabe et al., 2010). This seems to suggest that PCIT aligns well with Latinx cultural values.

Barriers to Treatment

            It is evident that Latinx families, especially those with LEP, may have trouble acquiring mental healthcare. In fact, there may be particular factors (i.e., barriers) that impede their ability to seek, access, and remain in treatment over time. Indeed, literature supports that there are three types of barriers impeding access to mental healthcare: (1) structural barriers (e.g., treatment cost); (2) attitudinal barriers relating to perception of mental health services (e.g., acceptance by community, comfort with a therapist); and (3) attitudinal barriers related to perceptions of mental health problems (e.g., inability to identify a child’s need for services; Owens et al., 2002). These barriers need to be studied in the Latinx cultural context to better understand if and how they interact with treatment outcomes. In this study, we examined a number of barriers: treatment cost, parental stress, attitudes regarding the ethnicity of the therapist, and acceptance of treatment skills by the community to determine how these factors may impact Latinx as compared to non-Latinx families.

The cost of mental health care is a large barrier to accessing care, with costs greatly increasing among the uninsured over the years (Rowan et al., 2013). Unfortunately, Latinx families are the leading uninsured racial/ethnic group living in the United States (31% vs. 9% of White families; Flores et al., 2005; Ku & Matani, 2001). Additionally, poverty rates in the United States among Latinx families remain higher than White, non-Latinx counterparts (see Morales et al., 2002). In 1999, national income statistics showed that 22.8% of Latinx individuals live in poverty compared to 7.7% of non-Latinx Whites (Kouyoumdjian et al., 2003). A reason for this may be that Latinx individuals with comparable skills to non-Latinx Whites are paid less for their work (Kouyoumdjian et al., 2003). Regardless, socioeconomic disadvantage is linked with an increased risk for mental health problems due to an increased number of stressors and has been identified as a barrier predicting therapy drop-out (Santiago et al., 2012; Kazdin et al., 1997). Barriers associated with poverty (e.g., transportation, finances, childcare) often prevent utilization of services and predict poor engagement and retention in mental health services (Davis et al., 2008; Snell-Johns et al., 2004). Low socioeconomic status has also been linked to lower parent expectancies for child therapy (Nock & Kazdin, 2001). The families participating in the current study fall below the median household income level in the United States, making cost a likely barrier to treatment.

Acceptance of Treatment Skills by Community

Latinx communities are often described as collectivistic with emphasis placed on cooperation with the community rather than individual accomplishments (McCabe et al., 2005). Latinx families may experience stigma associated with engaging in mental health treatment (McCabe et al., 2005). This stigma is possibly tied to familismo cultural values which emphasize the importance of family and place importance on resolving child emotional and behavioral problems within the family (McCabe, 2002). Due to the perceptions sometimes held by Latinx caregivers, families may be less willing to engage in or stay in treatment which can lead to lower therapy outcomes or a higher rate of attrition for this community. To evaluate attitudes as moderators, they were dichotomized (with responses less than 5 coded as 1 and responses greater than 5 coded as 2).

Comfort with Ethnicity of Therapist

Ethnic matching refers to the ethnic match between the therapist and family (Sue, 1988). It has been hypothesized that when ethnicities match, the therapist and family are more likely to share a common background and experiences, that fewer miscommunications will occur, and the therapeutic goals will be similarly understood by the therapist and family (Sue, 1988; Flicker et al., 2008). A 2011 meta-analysis found a moderately strong preference for a therapist of one’s own race/ethnicity and a tendency to perceive therapists of one’s own race/ethnicity slightly more positively than other therapists (Cabral & Smith, 2011). This meta-analysis also found the effects of racial/ethnic matching to be highly variable and concluded that there is almost no benefit to treatment outcomes from racial/ethnic matching across 53 studies (Cabral & Smith, 2011). In this study, Latinx families were able to choose to have treatment measures delivered in Spanish from bilingual clinicians, but we explored family perceptions of the therapeutic alliance and comfort with the therapist.

Current Study

Various cultural and attitudinal factors influence the likelihood of seeking services, remaining in services, and benefiting from mental health treatments among Latinx families (McCabe et al., 2005). Given these cultural and attitudinal factors for Latinx families, it is reasonable to expect that barriers may be present and impact family involvement in PCIT. The first aim of the current study was to compare structural barriers to treatment for Latinx families and non-Latinx families participating in PCIT. We hypothesized Latinx families would endorse cost and parental stress barriers more often than non-Latinx families. The second aim was to investigate treatment attitudes for Latinx families compared to non-Latinx families. We hypothesized Latinx families would report higher attitudes regarding comfort with therapist ethnicity (given that most therapists identified as Latinx) and lower acceptance of treatment skills by their community compared to non-Latinx families. The third aim was to compare treatment outcomes between Latinx and non-Latinx families participating in PCIT. We hypothesized Latinx families would report similar reductions in child disruptive behaviors as non-Latinx families. However, we also hypothesized treatment attitudes would moderate this relationship, with families holding less positive attitudes reporting lower reductions in behavioral problems. Finally, we examined treatment completion rates across groups. We hypothesized that Latinx families would report similar rates of treatment completion as compared to non-Latinx families.

Method

Participants

Families

Participants in the current study were 83 caregiver-child pairs who received PCIT from a community mental health agency in southern California. To be eligible to participate in the study, the child had to be between 2 and 7 years old and the family had to be seeking treatment for disruptive child behaviors at the mental health agency. Families were asked to select one primary caregiver to complete assessment measures. Primary caregivers had to be at least 18 years old and have legal custody of the child. Caregivers were primarily mothers (n = 68, 81.9%) and largely Latinx (n = 52, 62.7%). The average household income for the sample was $26,515.94 (SD = 23,182.91). Children participating in the study were also largely Latinx (n = 50, 60.2%) and were mostly male (n = 55, 66.3%). The mean age of the children participating in the study was 3.73 years (SD = 1.09). Analyses were run based on child ethnicity data (see Table 1).

Clinicians

Clinicians providing PCIT were licensed clinicians and certified PCIT therapists. Clinicians were all female (n = 9), approximately 37 years old (SD = 7.62) and the majority were Latinx (n = 5, 55.6%). Most clinicians (88.9%) spoke English as their primary language, while 44.4% of clinicians spoke Spanish as a secondary language. At the time of study initiation, clinicians had a mean of 8.33 years (SD = 5.68) of clinical experience with a mean of 4.89 years (SD = 3.95) of experience in providing PCIT.

Procedures

The present study utilized secondary data from a larger research project which examined the effectiveness of incentives on families’ treatment attendance (Quetsch et al., 2020). During this study, families were randomly assigned to two different groups: (1) PCIT as usual and (2) PCIT plus the inclusion of incentives. Specific behaviors (timely attendance, homework completion, and therapeutic skill mastery) triggered the provision of incentives in the second group. PCIT was delivered based on the original manual (e.g., McNeil & Hembree-Kigin, 2010) with the only adaptation being that families who spoke Spanish could opt to have treatment measures delivered in Spanish and could also have a clinician who spoke Spanish coach them in their preferred language. Caregivers were given measures at pre-treatment (before starting PCIT), mid-treatment (CDI mastery), and post-treatment (PCIT graduation) for measures related to child disruptive behavior. Additionally, caregivers completed measures assessing for barriers preventing treatment participation as well as perceptions of treatment over the course of PCIT at three different time points (the third session of CDI-3, mid-treatment, and post-treatment). Pre- and post-treatment child disruptive behavior scores were used in moderation analyses and to compare treatment outcomes. Barriers preventing treatment participation and perceptions of treatment scores that were collected at CDI-3 were used in the present study’s analyses. The measures were given at CDI-3 to assess families’ attitudes at the beginning of treatment: after enough time had passed that they had adjusted to treatment but not so much time that there was significant treatment dropout.

Measures

Behavioral Outcomes

Behavioral outcomes were assessed using the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000, 2001). The CBCL is a parent-report measure of child behavioral problems (ages 1.5 to 18 years). Parents rate their children on a 3-point Likert scale (0 = Absent to 2 = Occurs often) for 118 behavior problems. The CBCL has been shown to possess reliability, as well as convergent and discriminative validity (Nakamura et al., 2009). Although the CBCL produces several subscale scores, only the CBCL Total score was used in the current study.

Barriers to Treatment Participation

Barriers to treatment participation were measured using the Barriers to Treatment Participation Scale (BTPS) which is a 58-item measure evaluating psychological and practical barriers to participant engagement in treatment (Kazdin et al., 1997). Only two items were used in the current study: cost (“I felt that treatment cost too much”) and parental stress (“Treatment added another stressor to my life”). Each item was rated on a 5-point Likert scale ranging from 1 (Cost was fine/ No added stress from treatment) to 5 (Cost was much too high/ Treatment added a great deal of stress). Each item was dichotomized (no/yes) with response options 1-3 coded as “no” and response options 4-5 coded as “yes.” The BTPS has good reliability and structure and is reasonably valid (Nanninga et al., 2016). Although some families completed the measure in Spanish, a Spanish version of this measure has not yet been standardized. The BTPS was assessed at CDI-3.

Therapy Attitudes

Family attitudes towards therapy were measured using the Therapy Attitude Inventory (TAI). The TAI (Eyberg, 1993) is a 15-item caregiver-report measure of family perceptions of progress in treatment, relationship with the therapist, and satisfaction with treatment. Each item is rated on a 5-point Likert scale (1 = dissatisfaction/worsening, 5 = high satisfaction/ improvement). Individual items were explored to determine particular factors that may have impacted family outcomes more than others. Only two items from the TAI were used in the current study: 1) “Level of comfort with the ethnicity of your therapist/coach” and 2) “To what degree have the skills you learned in this treatment program been accepted by the people in your community (e.g., neighbors, other school/Head Start parent, friends).” The TAI has high internal consistency, an excellent Cronbach’s alpha (.91) and moderate external validity (Brestan et al., 1999). Although some families completed the measure in Spanish, a Spanish version of this measure has not previously been standardized. The TAI was assessed at CDI-3.

Treatment Completion

Clinicians recorded treatment completion rates. Graduation from PCIT required the successful completion of both the CDI and PDI phases.

Results

Demographic information and descriptive statistics on study variables by ethnicity are presented in Table 1.

Treatment Barriers and Attitudes

Chi-square tests could not be conducted to examine reported barriers between Latinx and non-Latinx families as the cell sizes were too small (ns < 5); therefore, descriptive statistics were presented for each barrier for each ethnic group (see Table 2). Overall, only n = 2 families (n = 1 Latinx families; n = 1 non-Latinx families) indicated that parental stress was a barrier to engagement in treatment. No families endorsed cost as a barrier to treatment (n = 0).

A t-test was conducted to examine the two treatment attitudes (comfort with the ethnicity of the therapist and lower community perceptions of treatment skills) between Latinx and non-Latinx families. For comfort with therapist ethnicity, there was not a significant difference between Latinx (M = 4.82, SD = .39) and non-Latinx families (M = 4.88, SD = .45), t(61) = -.51, p = .612 For acceptance of treatment skills by community, there was not a significant difference between Latinx (M = 4.10, SD = .99) and non-Latinx families (M = 4.13, SD =1.01), t(60) = -.11, p = .916.

Treatment Outcomes

A mixed-factor Analysis of Variance (ANOVA) compared reductions in child disruptive behaviors among Latinx and non-Latinx families. Results indicated a significant effect of time F(1, 31) = 57.76, p < .001, ηp2 = 0.65, such that CBCL scores significantly decreased from pre- to post-treatment for both groups. There was not a significant effect of ethnicity, F(1, 31) = 0.18, p = 0.679, indicating similar overall scores on the CBCL for both ethnic groups. Finally, the interaction between CBCL scores and ethnicity was not significant, F(1, 31) = 1.11, p = .300. Given the low endorsement of treatment barriers these variables were not examined as moderators in the current study.

 Two mixed-factor Analysis of Variances (ANOVA) were conducted with the two dichotomized attitudes variables entered into the model. For comfort with the therapist ethnicity, and consistent with the previous model, CBCL scores significantly decreased over time, there was not a significant main effect of ethnicity, and the main effect of comfort with therapist was not significant, F(1, 28) = 0.01, p = .920. Furthermore the interactions were not significant between CBCL scores and ethnicity, CBCL scores and attitudes, F(1, 28) = 0.09, p = .773, or the three way interaction, F(1, 28) = 0.40, p = 0.532. For acceptance of therapy skills by community, and consistent with the previous model, CBCL scores significantly decreased over time, there was not a significant main effect of ethnicity, and the main effect of acceptance of skills by community was not significant, F(1, 27) = 0.05, p = .832. Furthermore the interactions were not significant between CBCL scores and ethnicity, CBCL scores and attitudes, F(1, 27) = 0.13, p = .723, or the three way interaction, F(1, 27) = 1.37, p = 0.252.

Treatment Completion

A Kaplan-Meier survival curve analysis was conducted to determine if Latinx families remained in treatment for a similar number of sessions before dropping out than non-Latinx families. The overall graduation or treatment completion rate for the current study was 42.5% (n = 34), with 43.1% of Latinx families graduating (n = 22 of 51) and 41.4% of non-Latinx families graduating treatment (n = 12 of 29). Families did not significantly differ by ethnicity on the probability of graduating from treatment over sessions (χ2(1) = .04, p = .846; Figure 2). The mean termination-specific survival rates were 18.34 sessions for Latinx families and 15.95 sessions for non-Latinx families.

Discussion

This study is an important comparison of PCIT services for Latinx families as compared to non-Latinx families. Our results indicate PCIT had similar effect on reducing child disruptive behaviors from pre- to post-treatment. Most families (both Latinx and non-Latinx) indicated that neither cost nor added parental stress were barriers to engagement in PCIT. Furthermore, attitudes about the comfort with the ethnicity of the therapist and acceptance of the treatment skills within their community were comparable across Latinx and non-Latinx families and were relatively positive. These reported treatment attitudes did not moderate the relationship between ethnicity and outcomes. Finally, both ethnic groups did not significantly differ on graduation rates and number of treatment sessions attended.

Finding significant reductions in behavioral concerns is consistent with previous research demonstrating the effectiveness of PCIT (Thomas et al., 2017). Moreover, these reductions were similar for both ethnic groups, demonstrating the effectiveness of PCIT for families from different cultural backgrounds. The results seen in this study suggest that PCIT is effective with ethnically diverse families; however, the high level of therapist-client match, the efforts made by the research team to reduce barriers, and the fact that treatment was delivered in Spanish should be taken into consideration when interpreting these results.

In understanding the low endorsement of barriers (i.e., cost, stress), one possible explanation is that efforts from the community agency to reduce those barriers may have eliminated these concerns. More specifically, this community agency may have worked to reduce the cost of the treatment or all families had insurance, which may have also helped reduce the stress for parents. This notion is supported by the fact that this clinic primarily provides services to Medicaid clients. Another possibility is that we did not assess the barriers that impacted families the most. While the present study only explored cost and stress barriers, it is quite possible that these same families endorsed other barriers that were not examined, such as transportation issues or critical events interfering with a family’s ability to come to therapy (e.g., moving, losing a job; Kazdin et al., 1997).

When examining parental therapy attitudes, families reported high levels of overall satisfaction. These outcomes might demonstrate that the therapists worked to address family’s needs and cultural attitudes for both Latinx and non-Latinx families. For example, Latinx families in this study were able to choose to have measures delivered in Spanish; this may have contributed to high positive ratings by Latinx families who had LEP. Furthermore, multiple therapists delivered services in Spanish, potentially increasing the cultural sensitivity of the treatment delivery. Most of the families in this study were Latinx and most of the clinicians were also Latinx, possibly contributing to shared cultural understanding or experiences.   

Latinx and non-Latinx families demonstrated similar positive attitudes regarding the acceptance of treatment skills by community, meaning that although Latinx communities have been identified as possessing differing cultural values (Kumpfer et al., 2002; McCabe et al., 2005; Ramos et al., 2017), the treatment skills taught in PCIT were accepted by the communities of families participating in this study. Future research should evaluate the generalizability of these positive attitudes regarding acceptance of treatment skills by Latinx communities.

Moreover, Latinx families were shown to graduate at similar rates to non-Latinx families, meaning that Latinx and non-Latinx families shared similar rates of treatment dropout. Analyses were limited due to the high level of treatment dropout—planned analyses regarding the presence of barriers were unable to be completed due to the low cell sizes. Future research should explore factors contributing to therapy dropout in order to engage families and increase graduation from treatment. This might include the study of other barriers (Kazdin et al., 1997).

Strengths and Limitations

The current study included a diverse sample which allowed for questions to be asked exploring Latinx family experiences with PCIT; however, the sample was relatively small making comparisons of barriers and attitudes under powered. Even still, the collaboration with a local community mental health agency allowed for a diverse sample to be consented into the study that reflected the population of the community.

The finding that behavioral concerns reduced a similar amount for both ethnic groups should also be interpreted with caution given the small N values and the small non-Latinx sample that was used for comparison. Future research should build on the effectiveness of PCIT for diverse families by conducting more studies with larger sample sizes. Particularly for Latinx families, researchers should consider that the term “Latinx” comprises many different subcultures from many different countries with heterogeneity in socioeconomic status, education level, acculturation level, and English-language proficiency, among many other factors (Kouyoumdjian et al., 2003). The particular geographical origins and cultural values for the Latinx families participating in this study were not assessed limiting further analyses regarding group heterogeneity or homogeneity.

Although the barriers examined in the current study were not endorsed by the families participating in the study, future research should examine barriers to treatment, especially for the Latinx community. Previous research has shown that Latinx families under-utilize mental health services due to a number of barriers (Rastogi et al., 2012). In order to increase service utilization by Latinx families, it is important to understand and minimize these barriers to treatment (Rastogi et al., 2012). Additional research should also include examination of factors and cultural beliefs that might affect Latinx families’ experience of PCIT. (e.g., respeto, acculturation). Finally, although treatment measures (TAI, BTPS) were delivered in Spanish to allow for LEP individuals the ability to complete measures themselves, these Spanish-translated measures have not yet been standardized; it is possible that translation impacted the validity or reliability of measures.  

Results for the current study could indicate cultural modifications are not necessary for the effectiveness of this intervention, yet previous research has theorized that cultural modifications could improve treatment seeking, engagement and retention among Latinx families, which have historically been low for this population (Kapke & Gerdes, 2016). Treatment tailored for Latinx families might include increased focus on respeto culture by emphasizing the importance of respect in psychoeducation and during coaching, as well as providing appropriate psychoeducation during the child-directed portion of PCIT who may feel that the approach to discipline is too mild (McCabe et al., 2005). Furthermore, additional time focused on rapport building can encourage collaboration between therapists and Latinx parents who may feel hesitant to challenge the authority of the therapist (McCabe et al., 2005). Modifications may also be made in how the treatment is presented or disseminated to Latinx families to decrease stigma around the use of this treatment (McCabe et al., 2005). Overall, more research is needed into the unique needs of Latinx families and how to transform that knowledge into applicable interventions.

Conclusion

Overall, PCIT was effective in reducing behavioral problems for both Latinx and non-Latinx families and was well-received by families. Cultural beliefs can influence the impact of treatments to reduce child behavior concerns. While it is important for research to continuously examine ways to tailor interventions to various cultural backgrounds and linguistic needs, results from the current study suggest PCIT can be comparably effective for both Latinx and non-Latinx families. As with all therapy treatments, clinicians need to deliver services in a culturally sensitive framework.

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