Therapist, Parent, and Youth Perspectives of Treatment Barriers to Family-Focused Community Outpatient Mental Health Services

This exploratory qualitative study describes treatment barriers to receiving family-focused child mental health services for youths with disruptive behavior problems from multiple perspectives. Data were collected during a series of focus groups and interviews, including: 4 therapist focus groups (n = 26), 3 parent focus groups (n = 14), and 10 youth (10–13 years) semi-structured interviews. Data analysis followed inductive, iterative processes typical of qualitative research using an editing style and thematic content analysis approach. Therapist, parent, and youth stakeholder participants discussed perceived barriers to effective treatment, the problems with current child outpatient therapy, and desired changes (i.e., policy, intervention, etc.) to improve mental health services. Results indicate similar themes around treatment barriers and dissatisfaction with services within and across multiple stakeholder groups, including inadequate service system support, lack of family involvement and feeling overwhelmed with the complexities of families’ needs; however, parents and therapists, in particular, identified different contributing factors to these barriers. Therapists highly endorse using family-focused therapy and desire parent participation; however, parents feel unsupported by their child’s therapist. Parents’ report feeling blamed and not heard by service providers which negatively impacts their attitude about service delivery, causing discomfort and resistance to participation in their youth’s treatment. Youth also discussed dissatisfaction with mental health services, specifically related to their direct experiences in therapy, and desired more active, directive family-focused approaches. Overall, stakeholders reported much frustration and dissatisfaction with current community-based outpatient child therapy services. Study findings can inform service provision, intervention development, and future research.     

Understanding Barriers to Initial Treatment Engagement among Underserved Families Seeking Mental Health Services

This mixed method study examined factors associated with parents not attending their child’s mental health treatment after initially seeking help for their 2–5 year old child. It was part of a larger study comparing two evidence-based treatments among low-income racial/ethnic minority families seeking child mental health services. Of 123 parents who initiated mental health treatment (71?% African American or multi-racial; 97.6?% low-income), 36 (29.3?%) never attended their child’s first treatment session. Socio-demographic characteristics, parenting stress, depression, severity of child behavior problems, and length of treatment delay from intake to first scheduled treatment session were compared for families who did and did not attend their first treatment session. Parents who never attended their child’s first treatment session were more likely to live with more than four adults and children (p?=?.007) and have more depressive symptoms (p?=?.003). Median length of treatment delay was 80 days (IQR?=?55) for those who attended and 85 days (IQR?=?67.5) for those who did not attend their child’s first treatment session (p?=?.142). Three themes emerged from caregiver interviews: (a) expectations about the treatment, (b) delays in getting help, and (c) ambivalence about research participation. Findings suggest the need to develop better strategies for addressing risk factors early in the treatment process and reducing the length of time families with adverse psychosocial circumstances must wait for child mental health treatment.     

Gendered Division of Childrearing: Ideals,Realities, and the Relationship to Parental Well-Being

Recent cultural expectations about fathers' involvement in childrearing may have changed more rapidly than fathers' behaviors, creating discrepancies between parenting ideals and realities that can generate tensions in family life. In this study, a 1999 national probability sample of 234 married parents, both mothers and fathers expressed strongly egalitarian ideals that fathers should be equally involved in child-rearing across five nurturant domains—discipline, emotional support, play, monitoring, and care-giving—as well as in financial support. In contrast, mothers perceived much less father involvement in actual parenting than fathers perceived—especially in disciplining and providing emotional support for their children. Ideal–actual discrepancies were related to well-being: if fathers were seen as less than ideally involved in nurturant parenting, parents reported more stress and fathers who perceived greater than ideal father involvement in financial support were more likely to say the division of household labor was unfair to the mother. Ideal–actual gaps differed for mothers and fathers and were sometimes differentially related to well-being. For example, less than ideal father involvement in disciplining children was associated with mothers' higher stress levels, and the discrepancy in expectations about father involvement in play and monitoring children was correlated with mothers' increased feelings of unfairness in the household division of labor. On the other hand, fathers who felt an ideal–actual gap in disciplining children almost always felt overly involved in discipline and were less likely to report that the division of labor in the household was unfair to their spouses.     

Acculturation, communication patterns, and self-esteem among Asian and Caucasian American adolescents

This study examined level of acculturation, openness in communication with parents, peer interaction, and self-esteem in two ethnic groups-Asian and Caucasian American adolescents who grew up in the same neighborhood. The findings provide evidence of significant ethnic differences in behavioral patterns, peer networks, family contexts, and levels of self-esteem. In general, Asian adolescents expressed more difficulty discussing problems with their parents when compared to their Caucasian counterparts. Further, self-esteem was found to be significantly lower among Asians than Caucasians. Implications for the provision of mental health services are discussed.     

Acculturation Conflict,Cultural Parenting Self‐Efficacy,and Perceived Parenting Competence in Asian American and Latino/a Families

Parents from immigrant backgrounds must deal with normative parenting demands as well as unique challenges associated with acculturation processes. The current study examines the independent and interactive influences of acculturation conflict and cultural parenting self‐efficacy (PSE; e.g., parents’ confidence in instilling heritage, American, and bicultural values in their children) on perceptions of general parenting competence. Using data from 58 Asian American and 153 Latin American parents of children in grades 6–12, ethnic differences were also explored. Results suggest that lower acculturation conflict is associated with higher perceptions of general parenting competence for both Asian and Latin American parents. Higher cultural PSE is associated with higher perceived general parenting competence for Latino/a parents only. One significant interaction was found, and only for Asian Americans, whereby the negative association between acculturation conflict and perceptions of parenting competence was weaker for those who felt efficacious in transmitting heritage messages. Results are discussed in light of clinical implications and the need for further recognition and study of culturally relevant factors and frameworks among families from immigrant backgrounds.     

School administrators, parents, and sex education: a resolvable paradox?

The emergence of AIDS as an untreatable, lethal disease, responding to educational prevention strategies in high-risk populations, has brought the issues of sex education in the public schools to the forefront. However, administrators, teachers, and parents perceive different barriers to sex education implementation. This study, undertaken in a northeastern, multigenerational, ethnic city, characterized by adolescent pregnancy rates a third higher than the state overall, polled 42 junior and senior high school administrators regarding educational priorities, perceived barriers to expansion of sex education, and preferred methods of introducing sex education. Administrators perceive parents as a major barrier to the introduction of more formalized sex education in their schools. Paradoxically, these same administrators felt that parents were generally uncomfortable in talking to their children about human sexuality. Recommendations are offered from existing models of health education for resolution of administrators' conflicting views on parental roles.     

Understanding the psychological processes of the racial match effect in Asian Americans

Some studies on mental health outcomes research have found that when clients and therapists are ethnically or racially matched, this tends to be related to greater satisfaction and better outcomes. However, the precise underlying mechanism for the match effect has not been extensively examined. In this experimental study, we tested the effect of racial match on critical counseling processes (i.e., therapist credibility and the working alliance) using a sample of 171 Asian American respondents. We also examined Asian ethnic identification as a potential moderator of the racial match effect. Structural equation modeling analyses indicated that racially matched individuals perceived greater experiential similarity with the therapist than nonmatched individuals, and experiential similarity was positively associated with therapist credibility. Although racial match did not predict attitudinal similarity, attitudinal similarity was strongly related to the working alliance and therapist credibility. Counseling implications are discussed.     

Family, School, and Community Factors and Relationships to Racial–Ethnic Attitudes and Academic Achievement

This study examined family, school, and community factors and the relationships to racial–ethnic attitudes and academic achievement among 98 African American fourth-grade children. It has been posited that young people who feel better about their racial–ethnic background have better behavioral and academic outcomes, yet there is a need for more empirical tests of this premise. Psychometric information is reported on measures of parent, teacher, and child racial–ethnic attitudes. Path analysis was used to investigate ecological variables potentially related to children's racial–ethnic attitudes and achievement. Parental education and level of racial–ethnic pride were correlated and both were related to children's achievement though in the final path model, only the path from parental education level was statistically significant. Children whose teachers exhibited higher levels of racial–ethnic trust and perceived fewer barriers due to race and ethnicity evidenced more trust and optimism as well. Children living in communities with higher proportions of college-educated residents also exhibited more positive racial–ethnic attitudes. For children, higher racial–ethnic pride was related to higher achievement measured by grades and standardized test scores, while racial distrust and perception of barriers due to race were related to reduced performance. This study suggests that family, school, and community are all important factors related to children's racial–ethnic attitudes and also to their academic achievement.     

Therapist Focus on Parent Involvement in Community-Based Youth Psychotherapy

Parent involvement in the treatment of childhood disruptive behavior problems is a critical component of effective care. Yet little is known about the amount of time therapists are involving parents in treatment and factors that predict therapists' efforts to involve parents in routine care. The purpose of this study is to examine therapists' within-session involvement of parents in community-based outpatient mental health treatment. The data are from a larger longitudinal observational study of psychotherapy for children ages 4-13 with disruptive behavior problems and include videotaped psychotherapy sessions coded for the therapeutic strategies delivered as well as measures of child, parent/family, and therapist characteristics at baseline. Parent involvement is defined as the proportion of time in the session that therapists direct treatment strategies towards parents. Results indicated that therapists directed treatment strategies towards parents an average of 44% of the time within a session. Multilevel modeling was used to examine client-level (child, parent, and family functioning) and provider-level (therapist experience and background) predictors of parent involvement. Therapists involved parents more when the child had higher levels of behavior problems, when the parent reported higher levels of internalized caregiver strain, and when the therapist was more experienced. The results highlight potential areas to target in efforts to increase parent involvement, including training less experienced therapists to increase their focus on directing strategies towards parents.     

Therapist Experiences and Attitudes About Implementing Internet-Delivered Parent-Child Interaction Therapy During COVID-19

It has been widely recognized that access to mental health treatment is imperative to address current and long-term stressors for children and parents during COVID-19. Internet-delivered Parent-Child Interaction Therapy (iPCIT, previously referred to as I-PCIT) is a strong model for remote service delivery during social distancing restrictions due to its empirical base. However, this treatment modality was not widely implemented before COVID-19, likely due to barriers to providing telehealth services. This mixed methods study conducted a follow-up survey to gather therapist experiences (N = 223) in delivering iPCIT during COVID-19, including qualitative data on the benefits and challenges to delivering iPCIT. The vast majority of therapists (82%) indicated that they transitioned to deliver PCIT via telehealth in response to COVID-19. PCIT caseloads decreased slightly from the first survey to the COVID-19 follow-up survey, but the racial and ethnic composition of caseloads were not significantly different between the two surveys. Of the 183 therapists who transitioned to deliver PCIT via telehealth, 82% expressed interest in continuing to provide iPCIT following the COVID-19 pandemic. Reported benefits of iPCIT included decreased barriers to access and the ability to practice skills within the naturalistic home environment. Challenges to iPCIT were primarily issues with technology as well as other logistical barriers, which could limit engagement for some families. Findings from this study may be beneficial in improving future implementation of iPCIT during and post-COVID-19.     

Ethnic Match and Treatment Outcomes for Child and Adolescent Mental Health Center Clients

This study investigated the effects of client ethnicity and client‐counselor ethnic match on treatment outcomes (i.e., GAF‐difference [from the Global Assessment of Functioning Axis V rating of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, American Psychiatric Association, 1994] and client visitation) of 1,946 child and adolescent community mental health center clients. After controlling for 7 other variables, no differences were observed after adjustment among client ethnicities, age groups, or ethnic match on the GAF‐difference dependent measure. Ethnically matched African American child and adolescent clients had fewer mental health visits than did their nonmatched counterparts. Implications of these findings are discussed.     

Parenting Among Hispanic and Anglo-American Mothers With Young Children

Abstract

The authors examined parenting practices and developmental expectations among 38 Hispanic and 38 Anglo-American mothers living in the United States. Mothers of children 3 to 5 years of age completed the Parent Behavior Checklist (R. A. Fox, 1994), a 100-item measure of parents' developmental expectations, discipline, and nurturing practices. In addition, the authors appraised the Hispanic mothers' acculturation and selected them for participation if their scores on an acculturation scale indicated (a) that their lifestyle was predominantly Hispanic and (b) that they had not been assimilated into the dominant culture. The 2 ethnic groups were also divided by socioeconomic status (SES). There were significant main effects for ethnicity and SES on the discipline and nurturing scores but not on the expectations scores. The Hispanic and higher SES mothers reported higher discipline and lower nurturing scores than did the Anglo-American and lower SES mothers. An unexpected finding was the tendency for higher SES Hispanic mothers to report more frequent use of discipline than the other 3 groups.     

Parenting among Hispanic and Anglo-American mothers with young children

The authors examined parenting practices and developmental expectations among 38 Hispanic and 38 Anglo-American mothers living in the United States. Mothers of children 3 to 5 years of age completed the Parent Behavior Checklist (R. A. Fox, 1994), a 100-item measure of parents' developmental expectations, discipline, and nurturing practices. In addition, the authors appraised the Hispanic mothers' acculturation and selected them for participation if their scores on an acculturation scale indicated (a) that their lifestyle was predominantly Hispanic and (b) that they had not been assimilated into the dominant culture. The 2 ethnic groups were also divided by socioeconomic status (SES). There were significant main effects for ethnicity and SES on the discipline and nurturing scores but not on the expectations scores. The Hispanic and higher SES mothers reported higher discipline and lower nurturing scores than did the Anglo-American and lower SES mothers. An unexpected finding was the tendency for higher SES Hispanic mothers to report more frequent use of discipline than the other 3 groups.     

Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes

Across several decades the effects of matching clients with therapists of the same race/ethnicity have been explored using a variety of approaches. We conducted a meta-analysis of 3 variables frequently used in research on racial/ethnic matching: individuals' preferences for a therapist of their own race/ethnicity, clients' perceptions of therapists across racial/ethnic match, and therapeutic outcomes across racial/ethnic match. Across 52 studies of preferences, the average effect size (Cohen's d) was 0.63, indicating a moderately strong preference for a therapist of one's own race/ethnicity. Across 81 studies of individuals' perceptions of therapists, the average effect size was 0.32, indicating a tendency to perceive therapists of one's own race/ethnicity somewhat more positively than other therapists. Across 53 studies of client outcomes in mental health treatment, the average effect size was 0.09, indicating almost no benefit to treatment outcomes from racial/ethnic matching of clients with therapists. These 3 averaged effect sizes were characterized by substantial heterogeneity: The effects of racial/ethnic matching are highly variable. Studies involving African American participants demonstrated the highest effect sizes across all 3 types of evaluations: preferences, perceptions, and outcomes.     

Psychosocial Family Treatment for a 10-Year-Old with Schizoaffective Disorder

Schizophrenia spectrum disorders are rare in childhood and little is known about their psychosocial treatment. Relevant findings from the adult and child literature are reviewed. The case of 10-year-old “Michael” is presented, who participated in a randomized clinical trial of a psychoeducational family treatment for mood disorders. Following treatment, quantitative and qualitative data show that Michael's mood and social functioning improved, utilization of mental health services improved, the overall family emotional climate became more positive, and his parents felt supported. He no longer met criteria for a mood episode but continued to display psychosis. This family's response suggests that group psychoeducation may be an effective treatment for families of children with emerging schizophrenia spectrum disorders.     

Perceptions of the acceptability of parent training among Chinese immigrant parents: contributions of cultural factors and clinical need

Parent training (PT) is well established for reducing child externalizing problems; however, lower rates of engagement in PT among ethnic minority/immigrant families have been found. We assessed PT acceptability among Chinese immigrant parents and explored clinical and cultural factors that may be associated with acceptability. Participants were a community sample of 145 Chinese immigrant parents (84% mothers) between the ages of 32 and 65 years (M=43.3 years, SD=6.2) who had children (84 boys, 59 girls) between the ages of 4 and 17 years (M=10.7 years, SD=3.6). Results suggest that parents found positive reinforcement techniques significantly more acceptable, less problematic, and more likely to be supported by others than punishment-based techniques. Parents who endorsed the Chinese child-rearing value of shaming were less likely to find PT acceptable. Parents who reported greater dysfunction in parent-child interactions rated PT as more acceptable, and families with prior Child Protective Services (CPS) involvement rated PT as less acceptable. However, previous mental health treatment appears to bolster acceptability among parents with prior CPS involvement. Clinical implications for addressing barriers to PT engagement and future research directions are discussed.     

Perceived Barriers to Treatment Participation and Treatment Acceptability Among Antisocial Children and Their Families

This study examined the role of perceived barriers to participation in treatment and the acceptability of treatment among children and parents. Children (N = 144, ages 6–14) referred for outpatient treatment for oppositional, aggressive, and antisocial behavior and their families participated. The main findings were that: (a) perceived barriers to participation in treatment predicted treatment acceptability as rated by children and parents; (b) the effect was not accounted for by socioeconomic disadvantage, parent psychopathology and stress, and severity of child dysfunction; and (c) treatment acceptability was related to therapeutic change in the children over the course of therapy but the relation was small. Overall, the findings indicate that families vary considerably in the barriers they perceive in coming to treatment and that these barriers influence the extent to which they and their children evaluate the acceptability of the treatments they receive. The implications of treatment acceptability for evaluation and delivery of psychotherapy are discussed.     

One and One and One is Minus Three: Therapeutic Consultations in Child and Adolescent Mental Health Services with Separated and Conflicted Parents

Many children and young people attend mental health services where the conflict and dynamics between their separated parents contribute to their mental health difficulties. Without intervention in the conflicted co-parenting relationship, the child’s mental health may not improve. This article discusses the issues from the position of both children and their parents and describes some psychoanalytic thinking that can be applied in this work. This includes the development of triangular space and a third position in which the relationship itself is seen as a separate third and the understanding of grievance as a state of mind and a psychic retreat. The therapist’s countertransference offers insight into the experience of the child.     

'No-show': therapist racial/ethnic disparities in client unilateral termination

In the present study, the authors examined the source of racial/ethnic minority (REM) disparities in unilateral termination (i.e., the client ending therapy without informing the therapist)--a form of dropout that is associated with poor alliance and outcome. First, the authors tested whether some therapists were more likely to have clients who reported unilaterally terminating as compared with other therapists. Next, the authors examined 2 competing hypotheses regarding the therapists role in termination disparities: (a) that racial/ethnic disparities in unilateral termination are similar across therapists and thus due to other components of the treatment process or (b) that racial/ethnic disparities in unilateral termination are specific to therapists, where some therapists are more likely, on average, to have higher rates of unilateral termination with REM clients as compared with White clients. The sample included 155 REM clients and 177 White clients who were treated by 44 therapists at a university counseling center. The results showed that therapists accounted for a significant proportion of the variation in clients' unilateral termination, and REM clients were more likely to report they unilaterally terminated from therapy as compared with White clients. Furthermore, racial/ethnic disparities in clients' report of unilateral termination varied across therapists' caseloads. These results suggest that therapists have a central role in their clients' unilateral termination and have implications for understanding racial/ethnic mental health disparities.     

‘I didn't violent punch him’: parental accounts of punishing children with mental health problems

This paper examines the ways in which parents attending family therapy report how they discipline their children. The children are reported to have mental health problems and by the nature of their disorders present challenging behaviours. Within the family therapy setting, parents account for their methods of punishment which includes threatening, punching, hitting and smacking with belts. They report desires to inflict physical damage upon the child, contrast their punishment strategies against the extremeness of the child and co‐construct the essential and necessary nature of the discipline. Investigating parental perspectives has wider implications for child discipline and child protection and the growing social impact of discipline techniques for policy‐makers.