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Black Clinicians’ Perceptions of the Cultural Relevance of Parent–Child Interaction Therapy for Black Families

PMCID: PMC11507359

PMID:

Abstract

Parent–child interaction therapy (PCIT) is a highly efficacious, evidence-based treatment for children with disruptive behaviors and their families. PCIT is a dyadic therapy designed to improve parent–child relationships and decrease children’s behavioral problems. PCIT research specific to Black families is currently sparse. Given findings that Black families have a higher attrition rate and demonstrate fewer significant improvements in parental well-being outcomes, we sought to assess clinicians’ perceived cultural alignment of PCIT with Black families. We conducted individual interviews via Zoom with 10 Black clinicians, trained in PCIT, who had experience treating Black families using PCIT. The research team generated the following themes using thematic analysis: cultural misalignment, manualization, barriers to treatment, generational patterns of discipline, racial considerations, and protocol changes. Findings indicate that Black clinicians have identified various points of cultural misalignment in providing PCIT with Black families, for which they have modified treatment or suggested changes to improve cultural sensitivity. Collating suggested clinician modifications to inform a cultural adaptation of PCIT for Black families may contribute to a reduction in the attrition rate and improvement in outcomes for Black families participating in PCIT.

Full Text

Parent–child interaction therapy (PCIT) is a behavioral parent training (BPT) program that is considered to be evidence-based in effectively treating young children with disruptive behaviors via a family coaching model [1]. PCIT is distinct from other BPTs in that PCIT utilizes real-time, in vivo feedback to coach parents through specific interactions with their children to promote a secure parent–child relationship and decrease children’s disruptive behaviors [2]. PCIT has been found to improve parenting skills, decrease child behavior problems, and generalize benefits to untreated siblings [2]. While PCIT has shown efficacy with certain populations, there has been some debate as to whether the evidence exists to consider PCIT evidence-based for Black families [3]. Since the development of PCIT with White families in a rural context, an overwhelming majority of PCIT studies in the U.S. have been conducted with only-White or majority-White samples [3]. Further, there is a particular paucity of research in determining PCIT’s efficacy with Black families and whether adaptation is needed [4]. Of the PCIT studies conducted with at least some Black participants, research has shown a number of disparate outcomes between Black families and families of other racial/ethnic backgrounds. These findings include higher levels of attrition for Black families, longer treatment durations needed to achieve proficiency in the PCIT skills when compared to typically understood treatment lengths of 12–16 weeks [5], and no mitigating impact on parental stress or depression, which was observed in other families [6,7,8]. We sought to address whether a cultural adaptation of PCIT is warranted and assess the specific areas of adaptation needed.
PCIT is a heavily manualized BPT intervention [9]. Before beginning PCIT treatment, clinicians lead caregivers through a pretreatment assessment to determine appropriateness of fit, including a clinical interview, observation of caregiver–child play, and the caregiver’s completion of questionnaires like the Eyberg Child Behavior Inventory [10]. Clinicians document real-time observational data via the Dyadic Parent–Child Interaction Coding System (DPICS), a standardized behavioral observation system developed to assess the quality of caregiver–child interactions [11]. Clinicians’ consistent monitoring of caregivers’ behaviors during sessions via the DPICS metrics helps to track progress in skill acquisition over time [11].
PCIT researchers have made notable advances in adapting PCIT to increase the acceptability and effectiveness of PCIT with various populations and cultures (e.g., Mexican Americans and Native Americans) within the U.S. [4]. However, these research efforts into the effectiveness of PCIT remain at varying stages, wherein research with some populations remains in the recommendation and pilot stages [12,13] and other research investigations have produced systematically developed adaptations and examined the efficacy of these adapted interventions in randomized controlled trials [14]. For instance, McCabe et al. developed and validated Guiando A Niños Activos (GANA), a PCIT adaptation intended to meet the cultural nuances of Mexican American families [14,15,16].
The cultural adaptation process to develop GANA incorporated a structured procedure including reviewing literature, gathering input from Mexican American families and clinicians who serve the intended population, and incorporating feedback from stakeholders after a model was proposed [15]. In a randomized controlled trial (RCT), GANA was compared against treatment as usual (TAU) and the standard PCIT protocol [14]. Results from the RCT showed that both GANA and PCIT were more effective than TAU at improving children’s externalizing behavior problems and parenting stress, as well as having higher observed labeled praises and parental satisfaction rates. However, only GANA was also significantly more effective at improving all other parent-reported outcome measures over TAU and was shown to elicit significantly more father participation than TAU [14]. In a one-year follow-up study, GANA, but not PCIT, was found to significantly improve 6 out of 10 outcomes measured when compared to TAU, including externalizing and internalizing behavior [16]. Although there were no significant differences between GANA and PCIT on most studied outcomes, GANA significantly outperformed PCIT in improving children’s internalizing symptoms at follow-up. These findings indicate that a successful cultural adaptation likely requires attention to language as an identity marker, barriers to treatment and completion, and a group’s historical relationship to mental health services.
Researchers have also begun the cultural adaptation process with other minoritized populations in the US, including Native American families [12] and Puerto Rican families [13]. Though cultural adaptations of PCIT are ongoing for multiple minoritized populations in the U.S., scant research has focused on the need for a cultural adaptation of PCIT for Black families [4]. More recently, there has been evidence of promising treatment outcomes for a more personalized tailoring approach to PCIT, such as MY PCIT [17]. The MY PCIT adaptation focuses on the use and important need to incorporate preliminary assessments with families during the intake process focused on factors that may influence engagement and completion rates for ethnically minoritized families. The family’s assessment findings are used to specifically tailor PCIT treatment to meet the cultural needs and values of the family while maintaining fidelity to the underlying treatment model. Inherently, the concept is a good one that transcends various cultural affiliations. One concern with this approach is its overly general nature of the cultural assessment that may fail to capture the unique issues relevant to Black families, such as justified mistrust in research or healthcare settings, structural language considerations, or differing ethnic-racial socialization practices. Specifically, ethnic-racial socialization is a critical element in parenting in the formation of healthy racial identity for Black children [18], for which the literature speaks to positive child outcomes behaviorally, cognitively, academically, and socially [19,20]. Further, while MY PCIT identifies various assessment factors relevant to ethnically minoritized families as outlined in the research literature, it does not account for the dearth of research on barriers and facilitators to engagement specifically for Black families with young children.
Eyberg (2005) concluded that PCIT was an evidence-based treatment for young, white children with behavior disorders, but that there was a lack of evidence for PCIT being efficacious for Black families of young children with similar behavioral challenges. Nearly 20 years later, only a handful of peer-reviewed articles have been published examining outcomes for PCIT in majority-Black samples [7,21,22,23]. Moreover, only one article, a retrospective archival study of 18 Black parent–child dyads, has been published with a 100% Black sample [7]. Although researchers found that most Black mothers who met completion criteria for PCIT reported a significant reduction in their children’s behavioral problems, there was not a significant reduction in either maternal stress or depression from pre- to post-treatment [7]. Moreover, Black families demonstrated an overall attrition rate of 56%, with 70% of non-completers dropping out following the assessment and before beginning treatment [7]. The attrition rate found for Black families participating in PCIT was considerably higher than the 36% attrition rate found in a previous study with a majority-White sample [24].
In another study, researchers conducted a community-based pilot of PCIT with a focus on eliminating barriers to treatment for families with low-income and ethnically minoritized children (n = 14, 50% non-Hispanic Black children; 21% Black Hispanic children) [23]. Specifically, they sought to eliminate barriers to treatment by providing free transit cards for public transportation to sessions, offering to have sessions at a local daycare instead of at community mental health centers, accommodating participants’ requests for evening sessions, and exercising a liberal absence policy. Despite these efforts, overall attrition in the study was 71%. Researchers found that there was a clinically significant change in behavior among the children that completed treatment. However, researchers postulated that factors related to low SES, self-referral status, perceptions of culturally misaligned treatment, and high levels of treatment barriers affected attrition.
A couple of studies have compared PCIT to other early childhood-focused evidence-based treatments (EBTs) with majority-Black samples. For example, researchers compared PCIT and the Chicago Parenting Program in a majority-Black sample (n = 80 in the PCIT intervention; 72.5% Black caregivers) [22]. Clinicians rated parents participating in PCIT as more engaged than parents participating in the Chicago Parenting Program, with treatment completers attending 31 sessions on average. However, the overall attrition rate was 69.4% for families who attended at least one PCIT session. Identified barriers for families included lack of transportation and childcare for non-participating siblings; both were provided by the clinic for families in need. Lastly, a recently published study focusing on EBTs delivered to families in homeless shelters compared a time-limited version of PCIT (n = 70 in the 12-session PCIT intervention, 77% Black children) to time-limited Child–Parent Psychotherapy [21]. Overall, researchers found both interventions to significantly reduce parenting stress and increase positive parental verbalizations. However, only time-limited PCIT was clinically significant in reducing children’s externalizing behavior problems and parents’ negative verbalizations among treatment completers, although attrition from the point of intake was 56% (52% for those who began treatment). Moreover, researchers found that mothers who participated in time-limited PCIT had significant reductions in stress and negative verbalizations as well as significant increases in positive verbalizations compared to mothers in time-limited Child–Parent Psychotherapy. While a few studies have been conducted with majority Black samples, the focus has not been on cultural or racial differences in outcomes, and there is still much research needed to determine whether a cultural adaptation of PCIT is warranted for Black families.
Since Eyberg’s (2005) call to action, few studies have taken up the mantle of examining the efficacy of PCIT in treating mental health and behavior outcomes in Black families. While Black families have been included in some PCIT research studies, there is limited research focusing specifically on the experience of Black families completing PCIT or the effectiveness of PCIT within this population. As Black people are at risk for overdiagnosis of disruptive behavior disorders [25,26] and have high PCIT attrition rates as well as disparate outcomes [7,22,23], there is a clear need to explore the perceived suitability of PCIT for Black families. Asking clinicians about their implementation experiences is one way of understanding how EBTs like PCIT are perceived and adapted to fit diverse communities [27]. Our study is informed by a cultural adaptation process that included collecting data from clinicians who worked with the intended population to assess cultural congruence and accessibility of the intervention [14]. In the current study, researchers conducted qualitative interviews with Black-identifying clinicians trained in PCIT about their experiences providing PCIT to Black families in order to contribute meaningful insights from clinicians in the field serving the Black community. The goal of the study was to assess Black clinicians’ perceptions of the cultural fit of PCIT for Black families and modifications needed to improve the cultural alignment. With this study, researchers hoped to explore two primary lines of inquiry:
Participants were recruited from the PCIT international listserv, and one participant was referred to the study group by another clinician. Eligibility criteria for the study included being trained in PCIT, self-identifying as Black or African American, and having provided PCIT to at least one Black family. Participants were Black clinicians (n = 10) who provided PCIT to between 2 and 40 Black families (M = 15.3, SD = 14.7). All participating clinicians identified as female and ranged in age from 30 to 62 years old (M = 38.2, SD = 9.4). Half of the participants had doctorate degrees, and the other half had master’s degrees. All were licensed clinicians, with 40% of participants being licensed psychologists, 40% licensed in social work, and 20% licensed in counseling. Participants had between 5 and 40 years of experience providing therapy (M = 12.3 years, SD = 10.2) and between 2 and 11 years of experience providing PCIT (M = 5.4 years, SD = 3.6). Participants’ estimated percentage of Black families who successfully completed PCIT treatment with them ranged from 0% to 100% (M = 51.0 percent, SD = 34.1). See Table 1 for participant characteristics using pseudonyms.
The development of interview questions for this study involved an iterative process including members of the research team and a consultant with expertise in culturally adapting EBTs for Black families. Beginning with a literature review on previous PCIT cultural adaptations and treatment barriers for Black families conducted by the research team, the first author drafted an initial set of questions according to the specific stages of PCIT. The first author circulated the drafted questions to research team members and the consultant to elicit feedback. The first author convened multiple meetings with the research team to collaboratively refine and finalize the questions. During these discussions, the team sought to ensure that all questions were clear, relevant, and aligned with the research objectives. The research team revised questions as needed and agreed on the final set of questions (see Table 2 for a list of interview questions).
Given that existing research on this topic is scant, researchers drew from multiple methodologies to forge a comprehensive data analytic plan. Recognizing that Black points of view are lacking in PCIT research specifically and intervention research more broadly, a social constructivist theoretical approach was used wherein participants’ experiences and perceptions are valued and prioritized as important and critical data [28]. As described below, an inductive, codebook-oriented thematic analysis approach was taken to derive a preliminary codebook from a subset of participant interviews [29]. More specifically, a bottom-up strategy [30] was used in which a codebook was generated based on common holistic themes emerging across the interview dataset, for which codes were generated.
Clinician interviews were recorded and transcribed via Zoom and stored in Box. Before beginning analysis, members of the research team reviewed each video and cleaned each transcript for accuracy. After all the transcripts were cleaned, two black, female members of the research team independently reviewed the transcripts and compiled notes, which the senior researcher used to create the initial codebook. The senior researcher met with the coders via Zoom over several sessions to refine the codebook through the generation of new codes and synthesis of similar codes. While the original codebook was created using a bottom-up qualitative data-driven process, codebook refinement utilized a top-down process informed by the senior researcher’s wealth of expertise with the PCIT treatment modality, servicing Black families in treatment for close to 20 years, and the research literature associated with both. Thus, this top-down process was consistent with a deductive reflexive analytic approach for interpreting responses in the refining of the codebook [31,32]. See Appendix A for a copy of the final codebook [33].
We sought to achieve further transactional validity of our findings through a process of member-checking [34,35]. Researchers disseminated preliminary results to study participants to confirm the accuracy of themes generated from their interviews and to provide an opportunity for feedback. We sent participants a Powerpoint slide deck outlining an overview of the project, the themes and subthemes we generated based on the data, and a summary of the conclusions drawn from the data. We emailed participants with reminders multiple times over a 5-week period to encourage their response. Three of the 10 Black clinicians responded with positive feedback about the results, and there were no suggested edits.
Results of our thematic analysis of the clinician interviews are illustrated by the following six themes generated by the researchers: cultural misalignment (n = 10), manualization (n = 10), barriers to treatment (n = 10), generational patterns of discipline (n = 9), racial considerations (n = 10), and protocol changes (n = 10). The majority of the themes (i.e., cultural misalignment, manualization, barriers to treatment, and generational patterns of discipline themes) were derived directly from the codebook, as they were mentioned by the highest number of clinicians, as were the subthemes described within the themes. For two themes (i.e., “racial considerations” and “protocol changes”), we subsumed two themes with overlapping or complementary content under an umbrella theme and included the highest-rated subthemes across the themes in our results. Specifically, “racial considerations” is the summation of “bilingualism/biculturalism” and “systemic racism, discrimination & PCIT”, and “protocol changes” is the summation of “suggestions” and “clinician attributes”. The research team determined that combining themes in these two cases best showcased themes and subthemes with high count scores in a parsimonious fashion. Each theme and subtheme are further described below using pseudonyms for participants’ names. See Table 3 for a summary of themes and subthemes.
Clinicians described multiple areas of cultural misalignment they have observed when treating Black families using PCIT, including lack of cultural sensitivity, treatment phases of PCIT, perceptions of time-out, and concern regarding external judgment. These findings expand our knowledge on issues clinicians believe Black families may encounter with PCIT treatment, particularly in response to the CDI and PDI phases. Specifically, findings provide a window into some Black families’ reluctance to adopt aspects of treatment, including allowing the child to lead the play, ignoring misbehaviors, providing frequent labeled praises, and using effective commands and time-out. Findings add to previous research on Black parents’ perceptions of play therapy [36], and some findings support previous research documenting Black parents’ negative views on the effectiveness of time-out [37] and influence of extended family and community on parenting behaviors [38]. Families’ concerns about treatment recommendations and reactions from their support system may contribute to the high rates of attrition reported in PCIT studies with Black families, given that parents’ negative perceptions of treatment are a greater barrier to engagement in BPTs than logistical barriers [39]. Therefore, improving Black families’ perceptions of the benefit of treatment for their families is key to improving retention.
Participants discussed how PCIT lacks cultural sensitivity due to its rigid manualization, which is unfavorable for Black families’ successful completion. This finding is consistent with previous research, which found that clinicians often perceive EBTs, like PCIT, as too rigidly manualized to permit individualized tailoring of treatment [40]. Thus, EBTs, including PCIT, are not easily translated to diverse cultural groups [40]. A majority of clinicians interviewed discussed attempts at tailoring the treatment for the Black families they work with, especially regarding language and coding. Although the culturally sensitive translation of materials and concepts mirrors other culturally modified aspects of PCIT for Latino, Native American populations, and cultural groups in general [12,14,17], we are not aware of previous modifications to DPICS coding for other U.S.-based racially minoritized populations. Given the higher number of sessions needed to complete PCIT, previous studies on PCIT with Black families have either removed the requirement for meeting skill criteria goals in order to progress to the next stage of treatment [21] or suggested the removal of the skill criterion [22]. Adapting either the coding criteria to better align with AAVE or reconsidering the skill criteria goals may aid in improving retention of Black families.
Clinicians identified the time commitment required by PCIT and logistical considerations as major barriers for Black families completing treatment. This finding is in line with previous research showing that time commitment is a primary reason for attrition, as well as difficulties with childcare and transportation issues [41,42]. Additionally, clinicians shared that financial constraints were a large barrier for Black families, which is consistent with research showing that SES predicts treatment dropout [24]. While Black clinicians in our study described multiple adaptations to reduce the impact of treatment barriers on attrition (e.g., child-care for non-participating children, flexible appointment options), previous research with Black families with low SES has demonstrated that similar logistical supports were insufficient in reducing the high attrition rates in families [22,23]. These findings may indicate that adaptations to address the PCIT requirements, in addition to common treatment barriers, may be needed to reduce Black families’ attrition rates.
Black clinicians identified discussions regarding corporal punishment as an important area for increased cultural sensitivity for PCIT clinicians working with Black families. Given that Black children’s disruptive behavior has an increased likelihood of exacerbated and harmful consequences resulting from systemic racism [43], it is imperative to address corporal punishment within PCIT with the utmost sensitivity and understanding of its historical significance within Black families. Previous research has shown that Black parents endorse the use of corporal punishment at higher rates than White parents [44,45] and view corporal punishment as the discipline strategy yielding the most immediate compliance [46]. Although the preponderance of research has shown negative child outcomes associated with corporal punishment, research findings are mixed for Black children, with some studies finding that corporal punishment is associated with more externalizing behaviors and other studies finding that it is associated with fewer externalizing behaviors [44,45]. It is also important to note that clinicians’ reports of Black parents seeking to learn alternative forms of discipline support previous findings that Black parents use a variety of disciplinary methods with children and tend to favor discussions with children over corporal punishment [47]. Having a nuanced understanding of the literature on disciplinary practices and outcomes in Black families and taking a sensitive approach to discussions of corporal punishment may improve the perceived cultural sensitivity of PCIT with Black families.
Clinicians expressed concerns that PCIT culturally excludes Black families given racial incongruence with providers and the samples utilized to validate the treatment, Eurocentricity of the treatment, and cultural differences in parenting. Notably, a recent study found that 83% of Black caregivers reported it was important to have a mental health provider of the same race and ethnicity because they felt more comfortable working with someone of the same race, perceived that it was easier to build a rapport with their provider, and valued the representation of having a same-race provider for themselves and their children [48]. Furthermore, our finding related to Eurocentricity mirrors anecdotal reports from previous PCIT research with Black families that reported a Black participant believed PCIT represented a “White” parenting method [23]. Taken together, our findings contribute to knowledge regarding possible reasons for Black families’ high levels of attrition from PCIT and identify possible modifications that may enhance treatment engagement and satisfaction. Further, these findings highlight the important role that attention to ethnic-racial socialization practices could play in creating a more culturally responsive treatment protocol for Black families.
While a more in-depth assessment like the one done in My PCIT may be helpful in identifying barriers and providing psychoeducation to overcome those barriers, more may be needed in terms of deep structure change as well as clinician training, education, and competency development to account for the parenting context in which many Black parents operate. One cultural adaptation for Black families with young children noted the importance of embedding consideration for ethnic-racial socialization practices to inform multiple aspects of treatment, including alignment with parenting goals, content delivery, and how Black parents deliver important messages to their children [49,50]. Multiple clinicians in our study discussed navigating parental worry about safety or navigating racism directed toward their child or their family while employing PCIT skills and techniques. Ethnic-racial socialization goals for Black parents may include modeling and communicating messages around safety and coping with bias that are not readily aligned with the skill criteria of standard PCIT. To this end, clinicians engaging with this population must be sufficiently knowledgeable to be flexible enough to provide what is needed to foster necessary buy-in and maintain engagement throughout PCIT. The additional insight required to be culturally responsive to Black families may come through personal experiences, as is the case with many of the clinicians in this study, or through an approach to adaptation that includes identifying necessary components for modification.

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"[{\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B1-ijerph-21-01327\", \"B2-ijerph-21-01327\", \"B2-ijerph-21-01327\", \"B3-ijerph-21-01327\", \"B3-ijerph-21-01327\", \"B4-ijerph-21-01327\", \"B5-ijerph-21-01327\", \"B6-ijerph-21-01327\", \"B7-ijerph-21-01327\", \"B8-ijerph-21-01327\"], \"section\": \"1. Introduction\", \"text\": \"Parent\\u2013child interaction therapy (PCIT) is a behavioral parent training (BPT) program that is considered to be evidence-based in effectively treating young children with disruptive behaviors via a family coaching model [1]. PCIT is distinct from other BPTs in that PCIT utilizes real-time, in vivo feedback to coach parents through specific interactions with their children to promote a secure parent\\u2013child relationship and decrease children\\u2019s disruptive behaviors [2]. PCIT has been found to improve parenting skills, decrease child behavior problems, and generalize benefits to untreated siblings [2]. While PCIT has shown efficacy with certain populations, there has been some debate as to whether the evidence exists to consider PCIT evidence-based for Black families [3]. Since the development of PCIT with White families in a rural context, an overwhelming majority of PCIT studies in the U.S. have been conducted with only-White or majority-White samples [3]. Further, there is a particular paucity of research in determining PCIT\\u2019s efficacy with Black families and whether adaptation is needed [4]. Of the PCIT studies conducted with at least some Black participants, research has shown a number of disparate outcomes between Black families and families of other racial/ethnic backgrounds. These findings include higher levels of attrition for Black families, longer treatment durations needed to achieve proficiency in the PCIT skills when compared to typically understood treatment lengths of 12\\u201316 weeks [5], and no mitigating impact on parental stress or depression, which was observed in other families [6,7,8]. We sought to address whether a cultural adaptation of PCIT is warranted and assess the specific areas of adaptation needed.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B9-ijerph-21-01327\", \"B10-ijerph-21-01327\", \"B11-ijerph-21-01327\", \"B11-ijerph-21-01327\"], \"section\": \"1.1. Parent\\u2013Child Interaction Therapy\", \"text\": \"PCIT is a heavily manualized BPT intervention [9]. Before beginning PCIT treatment, clinicians lead caregivers through a pretreatment assessment to determine appropriateness of fit, including a clinical interview, observation of caregiver\\u2013child play, and the caregiver\\u2019s completion of questionnaires like the Eyberg Child Behavior Inventory [10]. Clinicians document real-time observational data via the Dyadic Parent\\u2013Child Interaction Coding System (DPICS), a standardized behavioral observation system developed to assess the quality of caregiver\\u2013child interactions [11]. Clinicians\\u2019 consistent monitoring of caregivers\\u2019 behaviors during sessions via the DPICS metrics helps to track progress in skill acquisition over time [11].\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B4-ijerph-21-01327\", \"B12-ijerph-21-01327\", \"B13-ijerph-21-01327\", \"B14-ijerph-21-01327\", \"B14-ijerph-21-01327\", \"B15-ijerph-21-01327\", \"B16-ijerph-21-01327\"], \"section\": \"1.2. PCIT Cultural Adaptations\", \"text\": \"PCIT researchers have made notable advances in adapting PCIT to increase the acceptability and effectiveness of PCIT with various populations and cultures (e.g., Mexican Americans and Native Americans) within the U.S. [4]. However, these research efforts into the effectiveness of PCIT remain at varying stages, wherein research with some populations remains in the recommendation and pilot stages [12,13] and other research investigations have produced systematically developed adaptations and examined the efficacy of these adapted interventions in randomized controlled trials [14]. For instance, McCabe et al. developed and validated Guiando A Ni\\u00f1os Activos (GANA), a PCIT adaptation intended to meet the cultural nuances of Mexican American families [14,15,16].\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B15-ijerph-21-01327\", \"B14-ijerph-21-01327\", \"B14-ijerph-21-01327\", \"B16-ijerph-21-01327\"], \"section\": \"1.2. PCIT Cultural Adaptations\", \"text\": \"The cultural adaptation process to develop GANA incorporated a structured procedure including reviewing literature, gathering input from Mexican American families and clinicians who serve the intended population, and incorporating feedback from stakeholders after a model was proposed [15]. In a randomized controlled trial (RCT), GANA was compared against treatment as usual (TAU) and the standard PCIT protocol [14]. Results from the RCT showed that both GANA and PCIT were more effective than TAU at improving children\\u2019s externalizing behavior problems and parenting stress, as well as having higher observed labeled praises and parental satisfaction rates. However, only GANA was also significantly more effective at improving all other parent-reported outcome measures over TAU and was shown to elicit significantly more father participation than TAU [14]. In a one-year follow-up study, GANA, but not PCIT, was found to significantly improve 6 out of 10 outcomes measured when compared to TAU, including externalizing and internalizing behavior [16]. Although there were no significant differences between GANA and PCIT on most studied outcomes, GANA significantly outperformed PCIT in improving children\\u2019s internalizing symptoms at follow-up. These findings indicate that a successful cultural adaptation likely requires attention to language as an identity marker, barriers to treatment and completion, and a group\\u2019s historical relationship to mental health services.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B12-ijerph-21-01327\", \"B13-ijerph-21-01327\", \"B4-ijerph-21-01327\", \"B17-ijerph-21-01327\", \"B18-ijerph-21-01327\", \"B19-ijerph-21-01327\", \"B20-ijerph-21-01327\"], \"section\": \"1.2. PCIT Cultural Adaptations\", \"text\": \"Researchers have also begun the cultural adaptation process with other minoritized populations in the US, including Native American families [12] and Puerto Rican families [13]. Though cultural adaptations of PCIT are ongoing for multiple minoritized populations in the U.S., scant research has focused on the need for a cultural adaptation of PCIT for Black families [4]. More recently, there has been evidence of promising treatment outcomes for a more personalized tailoring approach to PCIT, such as MY PCIT [17]. The MY PCIT adaptation focuses on the use and important need to incorporate preliminary assessments with families during the intake process focused on factors that may influence engagement and completion rates for ethnically minoritized families. The family\\u2019s assessment findings are used to specifically tailor PCIT treatment to meet the cultural needs and values of the family while maintaining fidelity to the underlying treatment model. Inherently, the concept is a good one that transcends various cultural affiliations. One concern with this approach is its overly general nature of the cultural assessment that may fail to capture the unique issues relevant to Black families, such as justified mistrust in research or healthcare settings, structural language considerations, or differing ethnic-racial socialization practices. Specifically, ethnic-racial socialization is a critical element in parenting in the formation of healthy racial identity for Black children [18], for which the literature speaks to positive child outcomes behaviorally, cognitively, academically, and socially [19,20]. Further, while MY PCIT identifies various assessment factors relevant to ethnically minoritized families as outlined in the research literature, it does not account for the dearth of research on barriers and facilitators to engagement specifically for Black families with young children.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B7-ijerph-21-01327\", \"B21-ijerph-21-01327\", \"B22-ijerph-21-01327\", \"B23-ijerph-21-01327\", \"B7-ijerph-21-01327\", \"B7-ijerph-21-01327\", \"B7-ijerph-21-01327\", \"B24-ijerph-21-01327\"], \"section\": \"1.3. PCIT with Black Families\", \"text\": \"Eyberg (2005) concluded that PCIT was an evidence-based treatment for young, white children with behavior disorders, but that there was a lack of evidence for PCIT being efficacious for Black families of young children with similar behavioral challenges. Nearly 20 years later, only a handful of peer-reviewed articles have been published examining outcomes for PCIT in majority-Black samples [7,21,22,23]. Moreover, only one article, a retrospective archival study of 18 Black parent\\u2013child dyads, has been published with a 100% Black sample [7]. Although researchers found that most Black mothers who met completion criteria for PCIT reported a significant reduction in their children\\u2019s behavioral problems, there was not a significant reduction in either maternal stress or depression from pre- to post-treatment [7]. Moreover, Black families demonstrated an overall attrition rate of 56%, with 70% of non-completers dropping out following the assessment and before beginning treatment [7]. The attrition rate found for Black families participating in PCIT was considerably higher than the 36% attrition rate found in a previous study with a majority-White sample [24].\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B23-ijerph-21-01327\"], \"section\": \"1.3. PCIT with Black Families\", \"text\": \"In another study, researchers conducted a community-based pilot of PCIT with a focus on eliminating barriers to treatment for families with low-income and ethnically minoritized children (n = 14, 50% non-Hispanic Black children; 21% Black Hispanic children) [23]. Specifically, they sought to eliminate barriers to treatment by providing free transit cards for public transportation to sessions, offering to have sessions at a local daycare instead of at community mental health centers, accommodating participants\\u2019 requests for evening sessions, and exercising a liberal absence policy. Despite these efforts, overall attrition in the study was 71%. Researchers found that there was a clinically significant change in behavior among the children that completed treatment. However, researchers postulated that factors related to low SES, self-referral status, perceptions of culturally misaligned treatment, and high levels of treatment barriers affected attrition.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B22-ijerph-21-01327\", \"B21-ijerph-21-01327\"], \"section\": \"1.3. PCIT with Black Families\", \"text\": \"A couple of studies have compared PCIT to other early childhood-focused evidence-based treatments (EBTs) with majority-Black samples. For example, researchers compared PCIT and the Chicago Parenting Program in a majority-Black sample (n = 80 in the PCIT intervention; 72.5% Black caregivers) [22]. Clinicians rated parents participating in PCIT as more engaged than parents participating in the Chicago Parenting Program, with treatment completers attending 31 sessions on average. However, the overall attrition rate was 69.4% for families who attended at least one PCIT session. Identified barriers for families included lack of transportation and childcare for non-participating siblings; both were provided by the clinic for families in need. Lastly, a recently published study focusing on EBTs delivered to families in homeless shelters compared a time-limited version of PCIT (n = 70 in the 12-session PCIT intervention, 77% Black children) to time-limited Child\\u2013Parent Psychotherapy [21]. Overall, researchers found both interventions to significantly reduce parenting stress and increase positive parental verbalizations. However, only time-limited PCIT was clinically significant in reducing children\\u2019s externalizing behavior problems and parents\\u2019 negative verbalizations among treatment completers, although attrition from the point of intake was 56% (52% for those who began treatment). Moreover, researchers found that mothers who participated in time-limited PCIT had significant reductions in stress and negative verbalizations as well as significant increases in positive verbalizations compared to mothers in time-limited Child\\u2013Parent Psychotherapy. While a few studies have been conducted with majority Black samples, the focus has not been on cultural or racial differences in outcomes, and there is still much research needed to determine whether a cultural adaptation of PCIT is warranted for Black families.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B25-ijerph-21-01327\", \"B26-ijerph-21-01327\", \"B7-ijerph-21-01327\", \"B22-ijerph-21-01327\", \"B23-ijerph-21-01327\", \"B27-ijerph-21-01327\", \"B14-ijerph-21-01327\"], \"section\": \"1.4. Current Study\", \"text\": \"Since Eyberg\\u2019s (2005) call to action, few studies have taken up the mantle of examining the efficacy of PCIT in treating mental health and behavior outcomes in Black families. While Black families have been included in some PCIT research studies, there is limited research focusing specifically on the experience of Black families completing PCIT or the effectiveness of PCIT within this population. As Black people are at risk for overdiagnosis of disruptive behavior disorders [25,26] and have high PCIT attrition rates as well as disparate outcomes [7,22,23], there is a clear need to explore the perceived suitability of PCIT for Black families. Asking clinicians about their implementation experiences is one way of understanding how EBTs like PCIT are perceived and adapted to fit diverse communities [27]. Our study is informed by a cultural adaptation process that included collecting data from clinicians who worked with the intended population to assess cultural congruence and accessibility of the intervention [14]. In the current study, researchers conducted qualitative interviews with Black-identifying clinicians trained in PCIT about their experiences providing PCIT to Black families in order to contribute meaningful insights from clinicians in the field serving the Black community. The goal of the study was to assess Black clinicians\\u2019 perceptions of the cultural fit of PCIT for Black families and modifications needed to improve the cultural alignment. With this study, researchers hoped to explore two primary lines of inquiry:\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"ijerph-21-01327-t001\"], \"section\": \"2.1. Participants\", \"text\": \"Participants were recruited from the PCIT international listserv, and one participant was referred to the study group by another clinician. Eligibility criteria for the study included being trained in PCIT, self-identifying as Black or African American, and having provided PCIT to at least one Black family. Participants were Black clinicians (n = 10) who provided PCIT to between 2 and 40 Black families (M = 15.3, SD = 14.7). All participating clinicians identified as female and ranged in age from 30 to 62 years old (M = 38.2, SD = 9.4). Half of the participants had doctorate degrees, and the other half had master\\u2019s degrees. All were licensed clinicians, with 40% of participants being licensed psychologists, 40% licensed in social work, and 20% licensed in counseling. Participants had between 5 and 40 years of experience providing therapy (M = 12.3 years, SD = 10.2) and between 2 and 11 years of experience providing PCIT (M = 5.4 years, SD = 3.6). Participants\\u2019 estimated percentage of Black families who successfully completed PCIT treatment with them ranged from 0% to 100% (M = 51.0 percent, SD = 34.1). See Table 1 for participant characteristics using pseudonyms.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"ijerph-21-01327-t002\"], \"section\": \"2.2. Interview Questions\", \"text\": \"The development of interview questions for this study involved an iterative process including members of the research team and a consultant with expertise in culturally adapting EBTs for Black families. Beginning with a literature review on previous PCIT cultural adaptations and treatment barriers for Black families conducted by the research team, the first author drafted an initial set of questions according to the specific stages of PCIT. The first author circulated the drafted questions to research team members and the consultant to elicit feedback. The first author convened multiple meetings with the research team to collaboratively refine and finalize the questions. During these discussions, the team sought to ensure that all questions were clear, relevant, and aligned with the research objectives. The research team revised questions as needed and agreed on the final set of questions (see Table 2 for a list of interview questions).\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B28-ijerph-21-01327\", \"B29-ijerph-21-01327\", \"B30-ijerph-21-01327\"], \"section\": \"2.6. Data Analytic Plan\", \"text\": \"Given that existing research on this topic is scant, researchers drew from multiple methodologies to forge a comprehensive data analytic plan. Recognizing that Black points of view are lacking in PCIT research specifically and intervention research more broadly, a social constructivist theoretical approach was used wherein participants\\u2019 experiences and perceptions are valued and prioritized as important and critical data [28]. As described below, an inductive, codebook-oriented thematic analysis approach was taken to derive a preliminary codebook from a subset of participant interviews [29]. More specifically, a bottom-up strategy [30] was used in which a codebook was generated based on common holistic themes emerging across the interview dataset, for which codes were generated.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B31-ijerph-21-01327\", \"B32-ijerph-21-01327\", \"app1-ijerph-21-01327\", \"B33-ijerph-21-01327\"], \"section\": \"2.6. Data Analytic Plan\", \"text\": \"Clinician interviews were recorded and transcribed via Zoom and stored in Box. Before beginning analysis, members of the research team reviewed each video and cleaned each transcript for accuracy. After all the transcripts were cleaned, two black, female members of the research team independently reviewed the transcripts and compiled notes, which the senior researcher used to create the initial codebook. The senior researcher met with the coders via Zoom over several sessions to refine the codebook through the generation of new codes and synthesis of similar codes. While the original codebook was created using a bottom-up qualitative data-driven process, codebook refinement utilized a top-down process informed by the senior researcher\\u2019s wealth of expertise with the PCIT treatment modality, servicing Black families in treatment for close to 20 years, and the research literature associated with both. Thus, this top-down process was consistent with a deductive reflexive analytic approach for interpreting responses in the refining of the codebook [31,32]. See Appendix A for a copy of the final codebook [33].\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B34-ijerph-21-01327\", \"B35-ijerph-21-01327\"], \"section\": \"2.6. Data Analytic Plan\", \"text\": \"We sought to achieve further transactional validity of our findings through a process of member-checking [34,35]. Researchers disseminated preliminary results to study participants to confirm the accuracy of themes generated from their interviews and to provide an opportunity for feedback. We sent participants a Powerpoint slide deck outlining an overview of the project, the themes and subthemes we generated based on the data, and a summary of the conclusions drawn from the data. We emailed participants with reminders multiple times over a 5-week period to encourage their response. Three of the 10 Black clinicians responded with positive feedback about the results, and there were no suggested edits.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"ijerph-21-01327-t003\"], \"section\": \"3. Results\", \"text\": \"Results of our thematic analysis of the clinician interviews are illustrated by the following six themes generated by the researchers: cultural misalignment (n = 10), manualization (n = 10), barriers to treatment (n = 10), generational patterns of discipline (n = 9), racial considerations (n = 10), and protocol changes (n = 10). The majority of the themes (i.e., cultural misalignment, manualization, barriers to treatment, and generational patterns of discipline themes) were derived directly from the codebook, as they were mentioned by the highest number of clinicians, as were the subthemes described within the themes. For two themes (i.e., \\u201cracial considerations\\u201d and \\u201cprotocol changes\\u201d), we subsumed two themes with overlapping or complementary content under an umbrella theme and included the highest-rated subthemes across the themes in our results. Specifically, \\u201cracial considerations\\u201d is the summation of \\u201cbilingualism/biculturalism\\u201d and \\u201csystemic racism, discrimination & PCIT\\u201d, and \\u201cprotocol changes\\u201d is the summation of \\u201csuggestions\\u201d and \\u201cclinician attributes\\u201d. The research team determined that combining themes in these two cases best showcased themes and subthemes with high count scores in a parsimonious fashion. Each theme and subtheme are further described below using pseudonyms for participants\\u2019 names. See Table 3 for a summary of themes and subthemes.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B36-ijerph-21-01327\", \"B37-ijerph-21-01327\", \"B38-ijerph-21-01327\", \"B39-ijerph-21-01327\"], \"section\": \"4. Discussion\", \"text\": \"Clinicians described multiple areas of cultural misalignment they have observed when treating Black families using PCIT, including lack of cultural sensitivity, treatment phases of PCIT, perceptions of time-out, and concern regarding external judgment. These findings expand our knowledge on issues clinicians believe Black families may encounter with PCIT treatment, particularly in response to the CDI and PDI phases. Specifically, findings provide a window into some Black families\\u2019 reluctance to adopt aspects of treatment, including allowing the child to lead the play, ignoring misbehaviors, providing frequent labeled praises, and using effective commands and time-out. Findings add to previous research on Black parents\\u2019 perceptions of play therapy [36], and some findings support previous research documenting Black parents\\u2019 negative views on the effectiveness of time-out [37] and influence of extended family and community on parenting behaviors [38]. Families\\u2019 concerns about treatment recommendations and reactions from their support system may contribute to the high rates of attrition reported in PCIT studies with Black families, given that parents\\u2019 negative perceptions of treatment are a greater barrier to engagement in BPTs than logistical barriers [39]. Therefore, improving Black families\\u2019 perceptions of the benefit of treatment for their families is key to improving retention.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B40-ijerph-21-01327\", \"B40-ijerph-21-01327\", \"B12-ijerph-21-01327\", \"B14-ijerph-21-01327\", \"B17-ijerph-21-01327\", \"B21-ijerph-21-01327\", \"B22-ijerph-21-01327\"], \"section\": \"4. Discussion\", \"text\": \"Participants discussed how PCIT lacks cultural sensitivity due to its rigid manualization, which is unfavorable for Black families\\u2019 successful completion. This finding is consistent with previous research, which found that clinicians often perceive EBTs, like PCIT, as too rigidly manualized to permit individualized tailoring of treatment [40]. Thus, EBTs, including PCIT, are not easily translated to diverse cultural groups [40]. A majority of clinicians interviewed discussed attempts at tailoring the treatment for the Black families they work with, especially regarding language and coding. Although the culturally sensitive translation of materials and concepts mirrors other culturally modified aspects of PCIT for Latino, Native American populations, and cultural groups in general [12,14,17], we are not aware of previous modifications to DPICS coding for other U.S.-based racially minoritized populations. Given the higher number of sessions needed to complete PCIT, previous studies on PCIT with Black families have either removed the requirement for meeting skill criteria goals in order to progress to the next stage of treatment [21] or suggested the removal of the skill criterion [22]. Adapting either the coding criteria to better align with AAVE or reconsidering the skill criteria goals may aid in improving retention of Black families.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B41-ijerph-21-01327\", \"B42-ijerph-21-01327\", \"B24-ijerph-21-01327\", \"B22-ijerph-21-01327\", \"B23-ijerph-21-01327\"], \"section\": \"4. Discussion\", \"text\": \"Clinicians identified the time commitment required by PCIT and logistical considerations as major barriers for Black families completing treatment. This finding is in line with previous research showing that time commitment is a primary reason for attrition, as well as difficulties with childcare and transportation issues [41,42]. Additionally, clinicians shared that financial constraints were a large barrier for Black families, which is consistent with research showing that SES predicts treatment dropout [24]. While Black clinicians in our study described multiple adaptations to reduce the impact of treatment barriers on attrition (e.g., child-care for non-participating children, flexible appointment options), previous research with Black families with low SES has demonstrated that similar logistical supports were insufficient in reducing the high attrition rates in families [22,23]. These findings may indicate that adaptations to address the PCIT requirements, in addition to common treatment barriers, may be needed to reduce Black families\\u2019 attrition rates.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B43-ijerph-21-01327\", \"B44-ijerph-21-01327\", \"B45-ijerph-21-01327\", \"B46-ijerph-21-01327\", \"B44-ijerph-21-01327\", \"B45-ijerph-21-01327\", \"B47-ijerph-21-01327\"], \"section\": \"4. Discussion\", \"text\": \"Black clinicians identified discussions regarding corporal punishment as an important area for increased cultural sensitivity for PCIT clinicians working with Black families. Given that Black children\\u2019s disruptive behavior has an increased likelihood of exacerbated and harmful consequences resulting from systemic racism [43], it is imperative to address corporal punishment within PCIT with the utmost sensitivity and understanding of its historical significance within Black families. Previous research has shown that Black parents endorse the use of corporal punishment at higher rates than White parents [44,45] and view corporal punishment as the discipline strategy yielding the most immediate compliance [46]. Although the preponderance of research has shown negative child outcomes associated with corporal punishment, research findings are mixed for Black children, with some studies finding that corporal punishment is associated with more externalizing behaviors and other studies finding that it is associated with fewer externalizing behaviors [44,45]. It is also important to note that clinicians\\u2019 reports of Black parents seeking to learn alternative forms of discipline support previous findings that Black parents use a variety of disciplinary methods with children and tend to favor discussions with children over corporal punishment [47]. Having a nuanced understanding of the literature on disciplinary practices and outcomes in Black families and taking a sensitive approach to discussions of corporal punishment may improve the perceived cultural sensitivity of PCIT with Black families.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B48-ijerph-21-01327\", \"B23-ijerph-21-01327\"], \"section\": \"4. Discussion\", \"text\": \"Clinicians expressed concerns that PCIT culturally excludes Black families given racial incongruence with providers and the samples utilized to validate the treatment, Eurocentricity of the treatment, and cultural differences in parenting. Notably, a recent study found that 83% of Black caregivers reported it was important to have a mental health provider of the same race and ethnicity because they felt more comfortable working with someone of the same race, perceived that it was easier to build a rapport with their provider, and valued the representation of having a same-race provider for themselves and their children [48]. Furthermore, our finding related to Eurocentricity mirrors anecdotal reports from previous PCIT research with Black families that reported a Black participant believed PCIT represented a \\u201cWhite\\u201d parenting method [23]. Taken together, our findings contribute to knowledge regarding possible reasons for Black families\\u2019 high levels of attrition from PCIT and identify possible modifications that may enhance treatment engagement and satisfaction. Further, these findings highlight the important role that attention to ethnic-racial socialization practices could play in creating a more culturally responsive treatment protocol for Black families.\"}, {\"pmc\": \"PMC11507359\", \"pmid\": \"\", \"reference_ids\": [\"B49-ijerph-21-01327\", \"B50-ijerph-21-01327\"], \"section\": \"4. Discussion\", \"text\": \"While a more in-depth assessment like the one done in My PCIT may be helpful in identifying barriers and providing psychoeducation to overcome those barriers, more may be needed in terms of deep structure change as well as clinician training, education, and competency development to account for the parenting context in which many Black parents operate. One cultural adaptation for Black families with young children noted the importance of embedding consideration for ethnic-racial socialization practices to inform multiple aspects of treatment, including alignment with parenting goals, content delivery, and how Black parents deliver important messages to their children [49,50]. Multiple clinicians in our study discussed navigating parental worry about safety or navigating racism directed toward their child or their family while employing PCIT skills and techniques. Ethnic-racial socialization goals for Black parents may include modeling and communicating messages around safety and coping with bias that are not readily aligned with the skill criteria of standard PCIT. To this end, clinicians engaging with this population must be sufficiently knowledgeable to be flexible enough to provide what is needed to foster necessary buy-in and maintain engagement throughout PCIT. The additional insight required to be culturally responsive to Black families may come through personal experiences, as is the case with many of the clinicians in this study, or through an approach to adaptation that includes identifying necessary components for modification.\"}]"

Metadata

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