7/24/2017. Acknowledgements FAMILIAS SANAS. Cultural Factors & Practical Barriers. ADHD & Latino Families. Standard Parent Management Training

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1 Acknowledgements FAMILIAS SANAS A Culturally-Adapted Treatment for Latino Youth with ADHD Marquette University Graduate Students Theresa Kapke, M.S. Margaret Grace, M.S. Anne Malkoff, B.A. Undergraduate Students Jacqueline Galindo, B.A. Madeleine Kanaley, B.A. Kelly Downes, B.A. Community Collaborators Co-Leader Al Castro, M.A. Agencies United Community Center Numerous Elementary Schools Funding National Institutes of Health (NIH) - National Institute of Child Health & Human Development (NICHD) - 1R2HD A1* *The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. ADHD & Latino Families Cultural Factors & Practical Barriers Attention-Deficit/Hyperactivity Disorder Commonly diagnosed mental health disorder in children Developmentally inappropriate levels of hyperactivity, impulsivity, and/or inattention Associated impairment in academic, social, and/or family functioning that continue into adulthood Effective psychosocial treatments include behavioral parent training Mental health disparities for Latino families Less likely to receive treatment More likely to prematurely drop out of treatment Cultural Factors Gender socialization Family/parenting values Collectivism Practical Barriers Lack of bilingual providers Lack of insurance/money Transportation issues Stigma Unfamiliarity with mental health system Preliminary Work Translation of assessment and treatment outcome measures Forward- and back-translation Development of culturally-adapted treatment Standard Parent Management Training 8, 2-hour group sessions DRC implementation Effective instructions Time out Positive reinforcement Token economy Planning ahead strategies Takeover of the DRC Closing/wrap-up Classroom intervention Daily Report Card 1

2 Development of CAT: Focus Groups Development of CAT Group Topic Example Questions Parental beliefs about etiology of and appropriate What do you think is the cause of this child s treatment for ADHD; parental expectations about barriers to problems? receiving treatment for ADHD What challenges do you think you would face when seeking help if this was your child? Parental beliefs related to marketing and delivering parent training; parental responses to idea of parent training Parental reactions to specific parent training sessions - school intervention, effective instructions, time out Parental reactions to specific parent training sessions - positive reinforcement, token economy - homework hour and routines, planning ahead If this was your child, do you think parent training would be helpful? What would help you buy into parent training? How would you feel about learning this skills? What would make it more appealing or effective for Latino families? How would you feel about learning this skills? What would make it more appealing or effective for Latino families? Coding Process Sessions transcribed and transcriptions double checked Major themes identified Each session coded by two individuals based on major themes Disagreements discussed and resolved by team Parent Training Modification Team Coded focus group data Recommendations from mental health providers working with Latino families Previous research General Treatment Adaptations Global Adaptations - Treatment More role plays Active parental coaching Simplified handouts with visual appeal Video demonstrations sent home Integration of home visits Global Adaptations - Assessment & Feedback Different terminology and focus Appropriate expectations about change Relevant rationale for homework completion Involvement of extended family members Practical Barriers Adaptations Educational rather than therapy Goal to make family more successful Evening classes in the community Classes free of charge with dinner and childcare Classes in Spanish by bilingual individuals Class-Specific Adaptations Daily Report Card (DRC) Increase parental involvement with school Provide culturally congruent rationale for DRC Address parental concerns about rewarding expected behavior Emphasize rewarding small improvements Effective Instructions Address potential role of traditional gender roles Address parental concerns (respect for authority) Use culturally congruent example of response to repeated noncompliance Positive and Negative Attention Revisit parental concerns about positive attention and traditional gender roles Provide culturally congruent rationale for positive attention Taking Over the DRC Increase parental involvement with school Simplify take-over process and make it more collaborative Ensure current teacher is on board for assisting with next year s DRC Final Tips for Success Instill hope Provide a few new tools 2

3 Newly Developed Class: Consistent Consequences Newly Developed Classes: Managing Routines Introduce natural consequences and removal of privileges and possessions Define, discuss, and role play Follow-up class with home visit Homework Determine each family s situation and needs Assist families in establishing a family routine around homework hour OR Assist families in identifying and enrolling their child in a communitybased program Assist families in developing a simple reward plan Follow-up class with home visit Checklists Determine each family s situation and needs Assist families in developing checklists for morning and/or bedtime routines Assist families in developing a simple reward plan Follow-up class with home visit Study Aims & Contributions Initial pilot to determine if culturally-adapted ADHD treatment (CAT) outperforms standard parent management training: Engagement and acceptability outcomes ADHD symptomatology and functional impairment Parental and family functioning Most significant contributions: First study to compare a culturally-adapted treatment for ADHD to standard treatment First study to examine treatment outcomes for ADHD in Latino children from families less oriented to U.S. mainstream culture Recruitment Participants & Method 17 Partners Bruce Guadalupe Community School and UCC Acosta Middle School St. Anthony St. Joseph s Academy Notre Dame Primary School and Middle School Sixteenth Street Community Health Centers Events Attended Back-to-school nights Parent-teacher conferences Staff meetings Other Methods Collaboration with pediatricians and mental health care providers Word-of-mouth referrals Participants 74 families recruited and assessed 61randomly assigned to treatment condition 100% Latino 72% male Mean age = 7.98 years (SD = 2.57) 26 Predominantly Inattentive, 7 Predominantly Hyperactive-Impulsive, 28 Combined 12 medicated Assessment & Treatment Engagement & Acceptability Outcomes Treatment Attendance & Retention Parental Engagement Therapy Attitude Inventory ADHD Symptomatology & Functional Impairment Parent/Teacher DBD Rating Scales Parent/Teacher ADHD FX-Scales Parental/Family Functioning Parenting Stress Index-4-Short Form Parenting Sense of Competence Scale Confusion, Hubbub, & Order Scale 3

4 Assessment Treatment - PMT Multi-method, multi-informant Focus on symptomatology AND functional impairment Scheduled assessment sessions based on families needs and preferences Evening and weekend sessions Option of scheduling at UCC or MU Provided childcare Multiple roles - case management Building relationships - family and school/teacher buy-in Collaboration with other healthcare providers Home Intervention 8 parent sessions in Spanish at MU Co-leaders with cultural competence training All materials and handouts provided in Spanish Childcare provided Classroom Intervention Weekly meetings scheduled around teachers preferences Strategies to decrease burden on teachers Parents attended first and last school meeting Treatment - CAT Treatment Outcomes 21 Home Intervention 8 parent classes in Spanish at UCC Co-leaders with cultural competence training All materials and handouts provided in Spanish Home visits Role of other caregivers Childcare provided Dinner from Café el Sol Classroom Intervention Engaged teachers in assessment and DRC process early Early parental engagement Weekly meetings scheduled around teachers and parents preferences Strategies to decrease burden on teachers Engagement & Acceptability Outcomes Greater parental engagement and maternal satisfaction Better parental attendance and retention ADHD Symptomatology & Functional Impairment Fewer ADHD symptoms and less functional impairment Effect size differences Parental/Family Functioning Less maternal and paternal-reported parenting stress Greater maternal and paternal-reported parental efficacy Less maternal-reported chaos in the home Effect size differences 23 Much needed resource to families and children Valuable support for schools without such resources Valuable supplemental support for local mental health/medical providers/social services providers Likely reduction of parental/family conflict and suspensions/expulsions/drop-out Empowerment of parents and effort to bridge gap between home and school environments Foundation for young children to develop into healthier functioning adults who are able to be successful in employment situations Reduction of stigma around a child who does not act normal Positive experience and connection to mental health service system 4

5 Moving Forward: Sustainability 25 The group-based approach resonates with the colectivismo cultural value of Latinos Resonates with the strong sense of familismo in Latinos - putting the needs of children and family first (measure of success and pride) Empowers parental figures to resolve their own challenges - reinforces the role of the father and mother (machismo, marianismo) in culturallyappropriate manner Imbedding the intervention within existing, recognized entities/organizations/schools makes it more acceptable and accessible to Latino parents Parents seeing the collaboration with a Latino organization with behavioral health providers brings credibility/acceptance 26 After treatment ends, team available to Attend IEP meetings Follow-up on recommendations from report Ensure DRC sustainability Assist in starting a new DRC at the start of the next school year Identify translator and assist with scheduling Empower parents to advocate for themselves and their families in the school setting Troubleshoot new difficult child behaviors in booster sessions 27 Moving Forward: Maintaining Relationships & Next Steps Maintaining Relationships Participating families, teachers, schools, and healthcare providers Next Steps Need for dissemination Training bicultural, culturally-competent healthcare providers Examine generalizability Strategies to decrease practical barriers to treatments DRC Understanding families who may benefit most from CAT Parental acculturation, ethnic identity, attitudes/expectations Moving Forward: Next Steps Next Steps Understanding ways to continue to promote positive treatment outcomes Attendance, retention, and engagement Environments that will help to support program over time Schools Outpatient mental health clinics Primary care clinics Funding 5