The GANA program: a tailoring approach to adapting Parent Child Interaction Therapy for Mexican Americans.

Abstract

The current manuscript describes the process of developing the GANA program, a version of PCIT that has been culturally adapted for Mexican American families. The adaptation process involved combining information from 1) clinical literature on Mexican American families, 2) empirical literature on barriers to treatment access and effectiveness, and 3) qualitative data drawn from focus groups and interviews with Mexican American mothers, fathers, and therapists on how PCIT could be modified to be more culturally effective. Information from these sources was used to generate a list of potential modifications to PCIT, which were then reviewed by a panel of expert therapists and clinical and mental health researchers. The resulting GANA program and ongoing research to evaluate its effectiveness with Mexican American families is described.

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Although extensive evidence documents the efficacy of clinical interventions for children in lab settings, few clinical trials have included sufficient numbers of ethnic minority children to permit generalization across cultures (Chambless et al., 1996; Miranda, 1996; Miranda, Azocar, Organista, Munoz, & Lieberman, 1996). According to Chambless et al. (1996), no research currently demonstrates psychotherapy treatment efficacy for ethnic minorities. Although there has been national acknowledgment of the need for effective services for youth, empirical research on treatments for ethnic minority children has lagged far behind the recognition of need for such services (Sue, 1998).

Latinos are currently the largest racial/ethnic minority group in the United States, making up 13.3% of the U.S. population in 2002 (U.S. Census Bureau, 2003). Between 1980 and 1999, the proportion of Latino children in the United States increased from 9% to 16%, a higher growth rate than any other racial or ethnic group (Hobbs & Stoops, 2002). The U.S. Census Bureau (2003) estimates that by 2050, almost 1 in 5 children in the United States will be of Latino origin. Clearly, existing mental health programs must examine how best to serve the mental health needs of this large and growing youth population.

Data suggest that existing mental health services may fall short in meeting the needs of Latino youth. Latino youth are much less likely to receive mental health services than Caucasians, despite rates of mental health problems that are as high as or higher than other ethnic groups (Kataoka, Zhang, & Wells, 2002; McCabe et al., 1999; U.S.D.H.H.S, 2001). When Latino families do enter therapy, they may be more likely to drop out of treatment prematurely than families from other ethnic groups (e.g., Huey, 1998). Dropout rates after the first outpatient therapy session by adult Mexican American clients have been as high as 60% to 75% (Kahn & Heiman, 1978; Miranda et al., 1976). Multiple factors contribute to this pattern of service underuse, but these findings suggest that traditional mental health services may need to be modified to be culturally responsive to Mexican American and other ethnic minority families (Miranda, 1996; Vega, 1992).

Unfortunately, few evidence-based recommendations on how to modify mental health services to be more culturally effective are available. Several methods of improving services for ethnic minorities have been proposed, including modifying service delivery systems (e.g. employing bilingual staff), assigning Latino clients to treatment modalities that are likely to be culturally congruent, and creating new treatments that incorporate cultural values into the treatments themselves (Rogler, Malgady, Costantino, & Blumenthal, 1987). While all of these approaches have promise, they also have limitations in terms of practicality and generalizability.

A New Approach to Developing Culturally Responsive Treatment: Modification of ESTs

We therefore propose a fourth method for developing culturally responsive treatments: that of that modifying Empirically-Supported Treatments (ESTs) to be more culturally responsive for ethnic minority clients. This approach has several advantages. First, building culturally effective treatments on the foundations of previously tested, efficacious treatments is an economical approach that takes advantage of years of research that have gone into developing mainstream treatments. It is likely that although efficacious treatments may need some modifications to be effective with specific ethnic minority groups, their core elements are still valuable for these populations. It is certainly important to test this assumption before we discard the rigorously evaluated treatments that currently exist. Second, modifying various aspects of existing treatments allows us to test some of the recommendations made by experts for improving the cultural responsiveness of treatments for feasibility and for their effect on treatment outcomes. By systematically evaluating different components, we can determine which modifications actually have a positive effect on treatment outcome.

The current study employs this approach by adapting Parent Child Interaction Therapy (PCIT), an EST that has been demonstrated to be highly effective for young children with behavior problems, to be more culturally effective for Mexican American families (Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993; Eyberg, Boggs, & Algina, 1995; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998). Although PCIT has demonstrated its efficacy with Caucasian children, parent training approaches have not been tested with minority children, despite theoretical considerations that suggest the success of parent training may be dependent on the parenting norms of a particular cultural group (Forehand & Kotchick, 1996). While PCIT includes features that suggest that it might be amenable to Mexican American culture (i.e., inclusion of both parents, structured, time-limited) other features may require modification.

This manuscript describes the process through which we developed a culturally modified version of PCIT, called Guiando a Ninos Activos (Guiding Active Children, or GANA). The current study's approach to identifying modifications to PCIT that might improve its cultural effectiveness is provided below, followed by a description of the resulting, adapted PCIT program. It is hoped that the detailed descriptions of the study methodology as well as the modified intervention can serve as a model for future adaptations of ESTs for Mexican Americans as well as for other cultural groups.

Approach to Cultural Modification

Because the empirical literature provides limited guidance on how to adapt treatments for ethnic minority families, we developed a modification process that included three steps:

1. Survey of Relevant Information: We gathered information regarding potential cultural adaptations to PCIT from a number of different sources: the clinical literature, the empirical literature, expert opinion, and qualitative data collected from Mexican American parents and therapists.

2. Development of Proposed Modifications: Information from all of these sources was combined to arrive at a set of proposed modifications to PCIT that should increase the cultural effectiveness of the program.

3. Review of proposed Modifications: Finally, these proposed modifications were reviewed by three groups of experts: a group of researchers with expertise in the adaptation of mental health treatments, a panel of Mexican American therapists that work clinically with Mexican American families, and Sheila Eyberg, the creator of PCIT. In this review, final decisions were made about the acceptability of the full package of proposed modifications both from a practical and theoretical perspective. Below, the information gathered in our survey of relevant information used to arrive at the proposed modifications is reviewed.

Clinical Literature

We conducted a comprehensive review of the clinical literature on the treatment of Latino families. This literature points out several modal (although not universal) characteristics of Latino families that are important to consider when adapting PCIT for Mexican American populations. First, Mexican Americans are described as placing a stronger emphasis on familism, or the importance of relations with family relative to friends or co-workers in comparison with European Americans, particularly in matters of childrearing and child discipline (Zuniga, 1997). Familism is a source of assistance…