Enhancing the Responsiveness of Family-Based CBT Through Culturally Informed Case Conceptualization and Treatment Planning

Family-based CBT has been shown to be effective in controlled settings for an array of youth mental health difficulties, yet disparities in treatment engagement and outcomes across culturally diverse groups remain. In practice, cultural minority families are less likely to reap the demonstrated benefits of supported programs. Although there have been tremendous advances in case conceptualization, leading models have largely ignored cultural factors, contributing to observed disparities. The present paper reviews recent advances in science-informed case conceptualization and highlights how such advances nonetheless have failed to provide guidance on systematically incorporating cultural formulation into assessment and treatment planning. We then build upon Christon et al. (2015) useful 5-stage model of science-based case conceptualization in an effort to move the field toward culturally informed case conceptualization. We highlight how leveraging cultural assessment—such as with the use of the Cultural Formulation Interview (CFI)—can facilitate the incorporation of cultural factors into each of the five stages of science-based case conceptualization. A case example is utilized to illustrate key opportunities for strategically incorporating relevant information gleaned from the CFI into culturally responsive care with youth and families.     

A Posture of Reciprocity: A Practical Approach to Collaboration Between Professionals and Parents of Culturally Diverse Backgrounds

The current emphasis on developing culturally responsive services for families of children with disabilities from culturally diverse backgrounds informs the need for professional self-awareness whereby professionals learn to recognize not only the cultural specificity of personal values and beliefs but also of their professional practice. We describe an approach, the posture of reciprocity, that enables professionals to acquire this level of cultural awareness. Examples to illustrate applications of the posture are provided.     

Genetic and environmental bases of childhood antisocial behavior: a multi-informant twin study

Genetic and environmental influences on childhood antisocial and aggressive behavior (ASB) during childhood were examined in 9- to 10-year-old twins, using a multi-informant approach. The sample (605 families of twins or triplets) was socioeconomically and ethnically diverse, representative of the culturally diverse urban population in Southern California. Measures of ASB included symptom counts for conduct disorder, ratings of aggression, delinquency, and psychopathic traits obtained through child self-reports, teacher, and caregiver ratings. Multivariate analysis revealed a common ASB factor across informants that was strongly heritable (heritability was .96), highlighting the importance of a broad, general measure obtained from multiple sources as a plausible construct for future investigations of specific genetic mechanisms in ASB. The best fitting multivariate model required informant-specific genetic, environmental, and rater effects for variation in observed ASB measures. The results suggest that parents, children, and teachers have only a partly "shared view" and that the additional factors that influence the "rater-specific" view of the child's antisocial behavior vary for different informants. This is the first study to demonstrate strong heritable effects on ASB in ethnically and economically diverse samples.     

The Development of the Universal Ethnic Identity Scale (UEIS) for use in an Australian context

The aim of the present research was to develop a measure that assessed the level of ethnic identification of adults from diverse ethnic backgrounds, as well as individuals' level of ethnic identification with a host culture following migration. In the first study, an ethnically diverse sample of 275 people (138 males and 137 females) responded to a range of new items, as well as items drawn from related scales. Factor analysis revealed three dimensions of ethnic identity that were labelled, “Pride in Ethnic Background and Language,”“Liking for Traditional and Social Activities of my Ethnic Group,” and “Sense of Belonging to This (host) Country.” This factor structure was evaluated in a second study with 1,007 (552 males, 455 females) adults from culturally and linguistically diverse backgrounds. A two‐factor structure provided the most parsimonious fit to the data but further investigation of the factor structure within ethnically diverse samples was recommended. The results are discussed in relation to theories of social identity as well as research on ethnic identification and adaptation.     

Challenges in Developing a Cultural Evidence‐Based Psychotherapy in the USA: Suggestions for International Studies

In this article, we underscore some of the cultural challenges and limitations of the evidence‐based psychotherapy (EBP) utilised within the USA with the hope that these problems will be avoided or ameliorated in Australia and other countries. Although the EBP research is very diverse and complex, we categorise this fast‐growing literature using a threefold classification system that underscores culture. This classification system is proposed to examine the influence of culture on EBPs. The three categories used are (a) universal evidence‐based psychotherapies or universal psychotherapies, (b) race and ethnic minority evidence‐based psychotherapies or racial/ethnic psychotherapies, and (c) cultural evidence‐based psychotherapies or cultural psychotherapies. After each category is described, its benefits and limitations are discussed, emphasising implications for culturally diverse and international studies. We conclude with suggestions to promote the advancement of a more effective and inclusive cultural EBP in which researchers from different countries can collaborate and learn from each other.     

A Community‐Responsive Adaptation to Reach and Engage Latino Families Affected by Maternal Depression

As family researchers and practitioners seek to improve the quality and accessibility of mental health services for immigrant families, they have turned to culturally adapted interventions. Although many advancements have been made in adapting interventions for such families, we have yet to understand how the adaptation can ensure that the intervention is reaching families identified to be in greatest need within a local system of care and community. We argue that reaching, engaging, and understanding the needs of families entails a collaborative approach with multiple community partners to ensure that adaptations to intervention content and delivery are responsive to the sociocultural trajectory of families within a community. We describe a cultural adaptation framework that is responsive to the unique opportunities and challenges of identifying and recruiting vulnerable families through community partnerships, and of addressing the needs of families by incorporating multiple community perspectives. Specifically, we apply these principles to the cultural adaptation of an intervention originally developed for low‐income African American and White families facing maternal depression. The new intervention, Fortalezas Familiares (Family Strengths), was targeted to Latino immigrant families whose mothers were in treatment for depression in mental health and primary care clinics. We conclude with key recommendations and directions for how family researchers and practitioners can design the cultural adaptation of interventions to be responsive to the practices, preferences, and needs of underserved communities, including families and service providers.     

Advances in Latino Family Research: Cultural Adaptations of Evidence-Based Interventions

The stark contrast between frequent calls for research and practice that are applicable across a broad spectrum of cultural and ethnically diverse groups and the dearth of empirical knowledge about Latino families provided the impetus for this special issue on advances in Latino family research. A focus on empirically based practice frames the issue, focusing specifically on how concepts (expressed emotion, parenting style) can be used within interventions, how Latino parents perceive efforts to deliver evidence-based interventions, and how pilot projects that delivered culturally adapted interventions in three separate cities impacted family functioning. In all, the introduction highlights the complexities for researchers in meeting the needs of the field to ensure that effective interventions are applicable across cultural groups. Meeting the challenges is important to address the need of the growing Latino population. Advances in intervention research with ethnic minorities also stand to contribute to the advancement of intervention research broadly. This special issue provides examples of efforts that are underway to better understand what treatments work for Latino families, provided by whom, for what specific problems, and in which specific circumstances, paving the way to begin attempting to answer a challenge posed more than 40 years ago by Gordon Paul.     

Home-Based vs. Clinic-Based Parent–Child Interaction Therapy: Comparative Effectiveness in the Context of Dissemination and Implementation

Disruptive child behavior disorders remain a major public health issue despite the proliferation of several strong Evidence-Based Practices (EBPs) for these children and their families. This may stem from barriers to treatment facing many families in need, particularly families with low resources. Home-based treatment may be best suited for this population; however, EBPs are not always available or tested as home-based interventions. The current study compares an intensive home-based adaptation of Parent Child Interaction Therapy (PCIT) to the standard clinic-based model in the context of a statewide implementation. As part of the statewide implementation, therapists entered archival data into an online system. Data was gathered for 314 families receiving PCIT, with 181 children in clinic-based PCIT and 133 in intensive home-based PCIT. Consistent with other trials of PCIT, results of the current study indicate that both versions of the therapy were effective in reducing child-behavior problems and increasing parenting skills; however, there were marked differences in attrition. Intensive home-based participants were twice as likely to complete treatment (64.66%) compared to clinic-based participants (33.15%) despite facing more adversity. These results underscore the importance of scientifically-sound adaptations of EBPs, as well as the role of comparative effectiveness studies as a critical tool in the integrative model of intervention science.     

The development of a culturally informed, family-focused treatment for schizophrenia

With the changing demographics in the United States, there is an increasing need for psychotherapy interventions that have been tailored for and empirically evaluated with culturally diverse groups. This article discusses the development and evaluation of a family-focused, culturally informed therapy for schizophrenia (CIT-S) that is currently being pilot tested at the University of Miami. Case examples of CIT-S with participating families are provided, along with a discussion of interesting and challenging cultural issues that we have encountered during the pilot phase of this treatment study.     

Utilizing Community Partnerships to Devise a Framework for Cultural Adaptations to Evidence-Based Mental Health Practice in Diverse Communities

Mental health disparities for diverse communities (particularly immigrants and people of color) in terms of access to evidence-based treatments, lack of education/awareness about mental health symptoms and treatment options, and lack of culturally responsive treatments have been frequently documented. Hence, diversity considerations in the diagnosis, assessment, and treatment of psychological disorders remain vital and imperative in clinical practice. There is also substantial work indicating that cultural values likely play an essential role in shaping how individuals conceptualize and experience mental or emotional health. Therefore, the present study was developed for community-engaged clinicians and researchers to outline the process by which to create a culturally responsive, evidence-based treatment framework for community mental health interventions in close partnership with communities of color. This study was conceptualized and designed collaboratively with community leaders across five different communities of color: African American/Black, Latino/a, Native American, Pacific Islander, and African immigrant communities in a major U.S. city. This paper describes the mixed methods for such a community-engaged collaboration, highlighting critical elements for ongoing culturally engaged clinical work/research, and providing recommendations for culturally adapted interventions for mental health based on specific process observations made in the current example.     

Culturally Competent Family Interventions: Review and Case Illustrations

Family therapy is often the treatment of choice for culturally diverse clients. This article provides a critical review of culturally competent assessment and intervention strategies for use with ethnic minority families in the U.S. A culturally informed view of the definition of family health and dysfunction is presented, basic structure and goals of family therapy are delineated, and family therapy process and techniques are addressed. Clinical vignettes are provided to illustrate critical points.     

Coparenting Conflict and Academic Readiness in Children of Teen Mothers: Effortful Control as a Mediator

Children's exposure to coparenting conflict has important implications for their developmental functioning, yet limited work has focused on such processes in families with diverse structures or ethnically and culturally diverse backgrounds. This longitudinal study examined the processes by which Mexican‐origin adolescent mothers' coparenting conflict with their 3‐year‐old children's grandmothers and biological fathers (N = 133 families) were linked to children's academic and social skills at 5 years of age, and whether children's effortful control at 4 years of age mediated the link between coparenting conflict and indices of children's academic readiness. Findings revealed that adolescent mothers' coparenting conflict with their child's biological father was linked to indices of children's academic and social school readiness through children's effortful control among girls, but not boys, whereas conflict with grandmothers was directly linked to boys' and girls' social functioning 2 years later. Findings offer information about different mechanisms by which multiple coparenting units in families of adolescent mothers are related to their children's outcomes, and this work has important implications for practitioners working with families of adolescent mothers.     

"Queremos Aprender": Latino Immigrants' Call to Integrate Cultural Adaptation with Best Practice Knowledge in a Parenting Intervention

Despite the unique and challenging circumstances confronting Latino immigrant families, debate still exists as to the need to culturally adapt evidence-based interventions for dissemination with this population. Following the grounded theory approach, the current qualitative investigation utilized focus group interviews with 83 Latino immigrant parents to explore the relevance of culturally adapting an evidence-based parenting intervention to be disseminated within this population. Findings from this study indicate that Latino immigrant parents want to participate in a culturally adapted parenting intervention as long as it is culturally relevant, respectful, and responsive to their life experiences. Research results also suggest that the parenting skills participants seek to enhance are among those commonly targeted by evidence-based parenting interventions. This study contributes to the cultural adaptation/fidelity balance debate by highlighting the necessity of exploring ways to develop culturally adapted interventions characterized by high cultural relevance, as well as high fidelity to the core components that have established efficacy for evidence-based parenting interventions.     

A Preliminary Evaluation of Functional Communication Training Effectiveness and Language Preference When Spanish and English are Manipulated

We evaluated whether differences in treatment effectiveness or preference between languages emerged across Spanish and English during functional communication training (FCT) for young children with developmental disabilities exposed to Spanish and English in the home environment. Participants were 2 young children with developmental disabilities who displayed destructive behavior maintained by social contingencies and whose families spoke Spanish and English at home. All procedures were conducted in the participants’ homes by their mothers with coaching from the investigator. The effectiveness of FCT was evaluated within a reversal design across baseline, FCT, and extinction conditions. A multielement design across language type (Spanish and English) was embedded within the reversal design during the extinction and FCT conditions to evaluate differences in treatment effectiveness across type of language. Finally, during all FCT sessions, a concurrent schedules design was used to evaluate participant preference for type of language. Results suggested that FCT was effective in reducing destructive behavior, increasing manding, and/or increasing task completion for these 2 participants across Spanish and English treatment conditions. Preference for the type of language did not emerge for either participant during FCT. Results are discussed in terms of the merits of systematically evaluating language variables when working with culturally and linguistically diverse families and children.     

Interculturalism: A new diversity ideology with interrelated components of dialogue,unity, and identity flexibility

Increased cultural diversity has led to considerable debate on how to best promote intergroup harmony within pluralistic nations. In the current research, we consider the nature of interculturalism, a new diversity ideology extensively discussed by political philosophers and policy-makers in Europe and beyond. Interculturalism consists of three interrelated components of dialogue, unity, and identity flexibility. Using data (N = 2,364) from three national surveys in two ethnically diverse nations (Netherlands and USA), we test a new measure of interculturalism and establish its independence from multiculturalism and assimilation. We then demonstrate that interculturalism predicts positive intergroup outcomes, over and above multiculturalism, and is in a theoretically meaningful way related to various criterion measures. Collectively, these studies establish the uniqueness of interculturalism from multiculturalism and demonstrate its promise for improving intergroup relations in culturally diverse nations.     

Interpersonal Psychotherapy—Adolescent Skills Training With Youth From Asian American and Immigrant Families: Cultural Considerations and Intervention Process

Although research has identified effective evidence-based depression prevention interventions for diverse youth, little is known about how the intervention process unfolds with immigrant family youth. This study utilized a qualitative approach to explore cultural and clinical differences in the implementation of Interpersonal Psychotherapy–Adolescent Skills Training (IPT-AST) in two schools, one serving youth from primarily immigrant, Asian American families and the second, youth from mostly nonimmigrant, non-Hispanic White families. A total of 131 IPT–AST sessions were audio recorded, transcribed, and coded for presence and patterns of cultural and clinical constructs. Results revealed that sessions with immigrant family youth were more likely to contain discussions of interpersonal problems characterized by estrangement, goals of spending time together with important others, mentions of emotion suppression and academic achievement expectations, conversations about acculturation, differences in value orientation, and discomfort with implementing new intervention skills. Dialogue from interventionist and youth exchanges is presented to illustrate how these themes emerged and were addressed by interventionists in a culturally responsive manner. The study highlights how IPT–AST with immigrant family and Asian American youth may unfold differently compared to youth from nonimmigrant families. Implications of findings for providers are discussed.     

Parent training with high-risk immigrant chinese families: a pilot group randomized trial yielding practice-based evidence

We studied the efficacy and implementation outcomes of a culturally responsive parent training (PT) program. Fifty-four Chinese American parents participated in a wait-list controlled group randomized trial (32 immediate treatment, 22 delayed treatment) of a 14-week intervention designed to address the needs of high-risk immigrant families. Parents were eligible for intervention if they were Chinese-speaking immigrants referred from schools, community clinics, or child protective services with concerns about parenting or child behavior problems. Retention and engagement were high with 83% of families attending 10 or more sessions. Results revealed that the treatment was efficacious in reducing negative discipline, increasing positive parenting, and decreasing child externalizing and internalizing problems. Treatment effects were larger among families with higher levels of baseline behavior problems and lower levels of parenting stress. Further augmentation of PT to address immigrant parent stress may be warranted. Qualitative impressions from group leaders suggested that slower pacing and increased rehearsal of skills may improve efficacy for immigrant parents unfamiliar with skills introduced in PT.     

Factor analysis of the Iowa family interaction rating scales

Observational coding systems are uniquely suited for investigating interactional processes in couples and families, but their validity in diverse populations is unknown. We addressed this issue by applying factor analysis to interactional data collected from couples in low-income neighborhoods and coded with the widely used Iowa Family Interaction Rating Scales (IFIRS). Our sample of 414 low-income, ethnically diverse newlywed couples each provided 24-min samples of problem-solving and social support behavior. Interrater reliabilities were strong, and the resultant factors--reflecting positive, negative, and effective communication--were very similar to those obtained with White middle-class samples. Additionally, couples were more negative, less positive, and less effective in problem-solving conversations than in socially supportive conversations, further supporting the validity of the IFIRS in this population. We conclude by discussing the strengths and shortcomings of the IFIRS when used in a low-income, ethnically diverse population.