The development and evaluation of a natural helpers' training program to increase the engagement of urban, Latina/o families in parent-child interaction therapy
Introduction
Urban children from ethnic minority backgrounds have heightened risk for developing conduct problems, as they are more likely to be exposed to community violence, live in poverty, and experience high levels of psychosocial stress in their families (Gershoff et al., 2007, Lanza et al., 2010). Simultaneously, they are less likely to access mental health services (Coker et al., 2009, Garland et al., 2005). Latina/o immigrant children are especially vulnerable to having untreated conduct disorders as mental health service utilization is lower than amongst U.S. born Latina/os (Chang, Natsuaki, & Chen, 2013). Logistical barriers, stigma surrounding mental health services, and a lack of culturally sensitive interventions all negatively impact service engagement (McKay & Bannon, 2004).
Abundant empirical evidence supports the efficacy of parent training for treating conduct problems in young children (Eyberg, Nelson, & Boggs, 2008), but these interventions are not reaching the majority of families that need them (Kazdin, 2008). When parenting programs are accessed by ethnic minority families, they may not be evidence-based (Morawska et al., 2012). This is concerning because standard community services are not as effective at improving parenting skills and child behaviors (McCabe & Yeh, 2009) or decreasing child maltreatment (Chaffin et al., 2004) as evidence-based parent training programs such as Parent-Child Interaction Therapy (PCIT; Eyberg & Funderburk, 2011).
Innovative approaches are necessary to address mental health disparities and increase the utilization of evidence-based treatments amongst minority families (Callejas et al., 2010, Kazdin and Blase, 2011). One suggested strategy is incorporating natural helpers (i.e., community health workers), community members who provide informal support, advice, and tangible aid to underserved families (Israel, 1985) into parent training programs (Acevedo-Polakovich et al., 2013, Calzada et al., 2005, Williamson et al., 2014). Various benefits have been identified for including natural helpers in the provision of children's mental health services (Hoagwood et al., 2010, Rhodes et al., 2007, Stacciarini et al., 2012): 1) they have established relationships and trust with the parents they serve; 2) they are capable of providing specific advice and guidance, along with referrals to available services; and 3) they frequently serve as community role models and impart skills by their own example. Natural helpers may be especially useful for Latina/o families, as research suggests higher rates of informal service utilization (e.g., peer-support) amongst this population (Garland et al., 2005, Villatoro et al., 2014).
Latina/o parents have expressed an interest in receiving parenting support from natural helpers (Niec et al., 2014) and natural helpers have expressed a desire to be trained to provide these services (Acevedo-Polakovich et al., 2014). Some efforts have trained natural helpers in the provision of evidence-based parent training programs, but these trainings have not been evaluated (Calzada et al., 2005, Williamson et al., 2014). For example, Calzada et al. (2005) described a protocol to train successful graduates of ParentCorps, a parent training prevention program delivered in urban, ethnically-diverse settings (Brotman et al., 2011), to assist professionals in delivering the intervention. This protocol emphasized a need to meet the varied educational backgrounds of the natural helpers being trained by providing structured but informal didactics, along with ongoing supervision. In order to understand how natural helpers may help to reduce mental health disparities, further research is necessary that describes and evaluates how they are trained (Rhodes et al., 2007). Evaluations of trainings should address how knowledge and behavior change over the course of training, as both are necessary to properly implement interventions (Beidas & Kendall, 2010). This paper describes and evaluates the feasibility of a training program intended to prepare natural helpers to increase recruitment and parental engagement in PCIT amongst urban, Latina/o families.
PCIT is a parent training program with strong evidence of efficacy in treating young children with conduct problems along with a wide range of other emotional and familial concerns (Carpenter et al., 2014, Chaffin et al., 2004, McCabe and Yeh, 2009). The program is conducted in two phases, the Child-Directed Interaction (CDI) phase is focused on enhancing the parent-child relationship, and the Parent-Directed Interaction (PDI) phase is focused on effective discipline practices (Eyberg & Funderburk, 2011). PCIT has demonstrated efficacy with Mexican-Americans (McCabe & Yeh, 2009) and Puerto Ricans (Matos, Bauermeister, & Bernal, 2009), and Latina/o parents generally react favorably to its core components (Niec et al., 2014).
Core components of PCIT include a focus on the parent-child relationship, the use of in vivo feedback (i.e., coaching) to reinforce the parent's skill acquisition, and the use of assessment-guided treatment (Eyberg & Funderburk, 2011). Parent training programs that focus on increasing positive parent-child interactions and require parents to practice new skills with their children in session have larger effect sizes than those without these components (Kaminski, Valle, Filene, & Boyle, 2008). Assessment-guided treatment guarantees that the parents have reached mastery criteria for child-led play and discipline skills before they graduate, which indicates that they have a high level of proficiency with the skills they need to manage their children's behaviors (Eyberg & Funderburk, 2011). Practicing parenting skills until mastery is reached may be especially important for immigrant families, as some of these practices are less culturally familiar and are therefore more challenging to implement successfully (Lau et al., 2011, McCabe et al., 2013).
Engaging urban, ethnic minority families in PCIT can be problematic, as these families demonstrate higher rates of dropout than are typically found in research studies (Lyon & Budd, 2010). Adaptations to PCIT have been made to increase parental engagement once parents are referred to treatment (Chaffin et al., 2004, Chaffin et al., 2009, McCabe and Yeh, 2009), but no known efforts have addressed strategies to improve recruitment of high-risk families into the program. Consequently, the engagement strategies that have been researched only help families who are already referred to treatment, but do not reach families who have not yet initiated services. Unfortunately, these families may have the highest need for services, and engaging them in treatment is imperative (McKay & Bannon, 2004).
As trusted members of the community, natural helpers are in a unique position to reach underserved families, refer them to treatment, and increase their engagement once they enroll in PCIT. Given these strengths, researchers and policy makers have increasingly advocated for the incorporation of natural helpers in mental health services (e.g., Acevedo-Polakovich et al., 2013, Kazdin and Blase, 2011, Rhett-Mariscal, 2008, Stacciarini et al., 2012). However, limited research has identified how to train natural helpers to best support evidence-based treatments. The involvement of natural helpers into parenting interventions, such as PCIT, must not detract from their effectiveness. Research suggests that parenting programs that include ancillary services (e.g., case management) may have diminished effectiveness, potentially due to parents and service providers becoming distracted from parent skill development (Chaffin et al., 2004, Kaminski et al., 2008). As natural helpers frequently provide ancillary services (e.g., Rhett-Mariscal, 2008, Rhodes et al., 2007, Stacciarini et al., 2012), which may not be evidence-based, it is critical that they receive training in strategies that could enhance engagement and outcomes. Potentially effective roles for natural helpers include recruiting families into care, preparing parents for the expectations of an evidence-based treatment (e.g., requirements of in-home practice), and providing treatment consistent support (e.g., additional opportunities for skill practice). By observing and promoting home skill practice, natural helpers may improve the quality of this important component of treatment. These roles are consistent with research on cultural adaptations of parent training, which suggest that additional modeling, monitoring of parental use of techniques, and rehearsal of parenting skills could improve outcomes for ethnic minority families (Lau, 2012).
The PCIT natural helper training program was developed in Miami, Florida through a community-academic partnership between a certified PCIT trainer and a nonprofit agency with a well-established natural helpers program to increase service accessibility and utilization amongst community members. Collaborations between community-based organizations and behavioral health service providers have several benefits for increasing treatment engagement with impoverished, ethnic minority families, which include improving: (1) the cultural and linguistic sensitivity of the services; (2) the reputation of the behavioral health service providers in the community; and in turn (3) the utilization of services by minority families (Callejas et al., 2010).
The community agency serves a high-risk population within an urban neighborhood with a high density of Latino immigrants. Approximately 73% of this neighborhoods residents self-identify as being foreign-born from countries and regions including Cuba, Central America, South America, Mexico, or the Caribbean (United States Census Bureau, 2007–2011, ConnectFamilias, 2014). Over 50% of the community self-identifies as not speaking English or not speaking English well, which may limit access to care (U.S. Census, 2007–2011). The majority of adult residents have not completed their high school education and the median household income is approximately $24,000, which is significantly lower than the median household income of residents across Florida (approximately $47,000; US Census, 2014). As identified through local community meetings with 332 residents across diverse locations within the neighborhood, a substantial proportion of residents in this community have need for and openness to psychological services, but access problems may greatly limit their ability to obtain these services (ConnectFamilias, 2014).
To date, no known research has evaluated the training and consultation needed for natural helpers to effectively support recruitment and engagement in PCIT. This evaluation of the training program was developed to inform the feasibility of such efforts. The objectives of this training and evaluation were to: (1) increase the natural helper's knowledge of PCIT; (2) determine if natural helpers could reach mastery criteria with PCIT-targeted parenting skills (Eyberg & Funderburk, 2011) so they could model these skills for parents in the community; and (3) determine if natural helpers could reliably conduct behavior observations of targeted parent behaviors and provide feedback to parents based on their skills practiced in the home.
Section snippets
Participants
Five natural helpers were included in the training, including four females and one male. The primary role of three of the natural helpers was providing referrals and in-home support to the families, and the primary role of the other two natural helpers was care coordination. All natural helpers were paid employees of the community agency, and worked between 20 and 40 h per week. Natural helpers were of Colombian, Guatemalan, Cuban, and Nicaraguan descent, and spoke Spanish fluently. Only one
Knowledge of PCIT
Natural helpers demonstrated an increase in overall knowledge of PCIT as measured by the 12-item, multiple-choice quiz. Knowledge of PCIT increased from pre-training (M = 4.00, SD = 2.00) to post-training (M = 9.20, SD = 2.17), with effect sizes in the large range (d = − 1.88). Although scores decreased somewhat from post-training to post-consultation (M = 8.00, SD = 1.58), these scores remained higher than scores at pre-training (d = − 1.92).
Child-led parenting skills
On average, natural helpers demonstrated a large increase in their
Discussion
Pervasive challenges related to recruiting and retaining low-income, ethnic minority families into evidence-based parent training programs have significantly limited the public health impact of these interventions (Hoagwood et al., 2014). As members of the communities they serve, natural helpers are in an excellent position to guarantee that underserved, immigrant families receive the benefits of effective treatments, such as PCIT. However, limited research has investigated the training needs
Limitations and future directions
While this study represents an important first step to exploring the utilization of natural helpers within behavioral parent training, there are some limitations to the findings of this evaluation. First, this represents a first attempt to evaluate the feasibility of training natural helpers to utilize skills similar to PCIT therapists and the training cohort represents a very small sample size. It is not clear at this point if training outcomes are generalizable or if positive findings, such
Acknowledgements
Funding for this project was provided by The Children's Trust (grant no. 1610-7570 and 1621-7440).
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