EXPLORING THE RELEVANCE OF A CULTURALLY ADAPTED PARENTING INTERVENTION FOR LOW-INCOME ETHNIC MINORITY FAMILIES INVOLVED IN THE CHILD WELFARE SYSTEM: A QUALITATIVE STUDY WITH PARENTS AND INTERVENTIONISTS By Gabriela Alejandra López Zerón A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Human Development and Family Studies – Doctor of Philosophy 2017 ABSTRACT EXPLORING THE RELEVANCE OF A CULTURALLY ADAPTED PARENTING INTERVENTION FOR LOW-INCOME ETHNIC MINORITY FAMILIES INVOLVED IN THE CHILD WELFARE SYSTEM: A QUALITATIVE STUDY WITH PARENTS AND INTERVENTIONISTS By Gabriela Alejandra López Zerón Child maltreatment is recognized as a major public health issue in the United States. In the federal fiscal year 2014, roughly 6.6 million children were referred to child welfare agencies in the nation. Developmental, emotional, behavioral, and cognitive problems are prevalent among children referred to child welfare services (CWS). For those in foster care, temporary or permanent placement frequently introduces additional instability to a child’s already chaotic life, increasing their risk for deleterious physical and mental health outcomes. Limited research exists documenting the impact of efficacious parent training (PT) interventions aimed at serving lowincome ethnic minority families involved in child welfare services. This study constitutes a response to this gap in research. Specifically, an exploratory qualitative study was implemented with 14 low-income ethnic minority parents with recent CWS involvement. To be eligible, all parents met the following inclusion criteria: (a) successfully completed an evidence-based PT intervention as a requisite for reunification with their children, (b) discharged from CWS at the time of recruitment, and (c) reunified with their children. Data were also collected from 8 certified interventionists who delivered the evidence-based parenting intervention. A thematic analysis approach was used to collect, analyze, and interpret the data. Research findings contribute to the existing empirical literature associated with the dissemination of evidencebased PT interventions within CWS contexts. Research and clinical implications are discussed. Copyright by GABRIELA ALEJANDRA LÓPEZ ZERÓN 2017 To my parents, Vilma Zerón Marín and Alejandro López Alfaro and brother, Alejandro López Zerón Su incansable apoyo, ejemplo inspirador e infinito cariño sin lugar a duda guiron mis pasos hasta alcanzar esta meta. iv ACKNOWLEDGMENTS As I approach the end of this journey, I am incredibly humbled by the support I have received by so many wonderful souls. I am forever grateful to everyone who has been by my side, physically, emotionally, and/or spiritually. You all have certainly touched my life in profound ways. First and foremost, I would like to thank the parents who were willing to share their stories with me. Thank you for allowing me the privilege of listening to your experience. I am truly honored to be the one to elevate your voices and share your experiences with the larger community. I am also incredibly thankful for my community partners who contributed to this study in so many ways. I am grateful for everyone at the Coalition for Hispanic Family Services who warmly opened their doors to me, in particular all the interventionists who shared their experiences with me. I would especially like to thank Alexandria Muñoz and Andreina Silvera. Without your guidance and commitment, this project would have not been possible. I am inspired by your passion for social justice and commitment to the families you serve. I am also grateful for the collaboration of Dr. Marion Forgatch and Laura Rains from Implementation Science International, Inc. and Howard Sklar from the Administration for Children’s Services Research Review Committee for their valuable collaboration and guidance designing this research investigation. Finally, I am incredibly grateful to those who participated in the transcription of these interviews with such care and dedication. I would like to especially thank Mary Scholl for taking part in this project and providing me with such wonderful support! It has been a complete honor to work with an amazing doctoral guidance committee. I am profoundly grateful for your guidance and support throughout this process. I am honored to have v had the opportunity to learn from each of you. I would like to thank my advisor and doctoral committee chair, Dr. Ruben Parra Cardona. I am so grateful for your dedication and mentorship to my professional and personal development. You have certainly taught me so much about research, academia, and life. Your work ethic, dedication to the families we serve, and unwavering commitment to social justice are an inspiration to me. I am honored to call you my mentor and friend – this is certainly just the beginning! I would also like to thank Dr. Cris Sullivan for her steady guidance, support, and encouragement. I am incredibly grateful for the opportunity to learn from you in so many ways. I am constantly inspired by your passion and dedication to truly honoring and respecting the experiences of survivors and their families in research and practice. You are undoubtedly a great role model and I am so grateful to have such an inspiring woman to look up to. I would also like to thank Dr. Amy Bonomi and Dr. Adrian Blow for their commitment, generous financial support, and guidance throughout my doctoral training. I also very much appreciate your thoughtful feedback and willingness to share your expertise with me. Thank you for supporting me and believing in my work. I would certainly not be here today without the support of my loved ones. Queridos Mamita y Daddy, I am forever grateful for your love, encouragement, and wise advice. Thank you for all the sacrifices you have made so that I could follow my dreams. I am humbled by your unconditional love and by your trust and belief in me. Thank you for being fantastic parents, but also for being great friends! Querido frate, Ale, I am so grateful to have you in my life, not only as my brother, but also one of my best friends. Your love, support, and friendship mean the world to me. I am so glad that we only seem to get closer as we age. Thank you for all the awesome B.A.S.E. trips, nights out in SPS, and for being there for me every time I’ve needed it. Querida Enits, my dear grandmother, thank you for your unconditional love and support. I would vi also like to thank all my beloved extended family for always rooting for me and encouraging me to keep going! I am especially grateful for my loving partner, Nathaniel Scholl. Nathan, I do not have enough words to thank you for your kind patience, loving encouragement, and for believing in me throughout this process. I could have not made it to the finish line without your support. Thank you for bringing balance to my life and for giving me the strength I needed when I was hanging on by a thread. I am incredibly lucky to have you in my life! To my dear friends who loved and supported me throughout this journey, I could not have done this without you! Krissnaya Sosa, mi amiga del alma, thank you for your encouragement, honesty in all things, but also kind understanding. José Suarez, aka Kiko, you are like a brother to me. Thank you for always being there for me en las buenas y en las malas. Natasha Kovalova, thank you for being a wonderful friend and for all the great times we have had together. I am sure there are more to come! Queridos Rocío Escobar Chew y Douglas Gordillo, thank you for your warm welcome to Michigan and for your unconditional support and lovely friendship. I cannot wait for our paths to cross again soon. Jenni Chain and Nina Hidalgo, my lovely UO friends, thank you for your encouragement and inspiration throughout these years. To my StL crew, your true and honest friendship during this journey kept me sane. Thank you for always being there for me and for believing in me. I love you guys and I am so happy to call each and every one of you my friend! To my HDFS and RCGV colleagues, thank you for sharing this experience with me. Adam Farero and Becca Kammes, thank you for always lending a kind listening ear and for being great and supportive friends. To my Eco friends, thank you for welcoming me into your academic community as an honorary eco student. Finally, I would like to thank all those who I cannot explicitly acknowledge in these pages. Please know that your generous contributions and support have not gone unnoticed. Thank you! ¡Gracias! vii TABLE OF CONTENTS LIST OF TABLES ..................................................................................................................... xii LIST OF FIGURES .................................................................................................................. xiii CHAPTER 1: INTRODUCTION ................................................................................................1 Statement of the Problem ......................................................................................................1 Parent Training Interventions as an Alternative to Address Child Maltreatment ..................2 Parent Management Training – the Oregon Model (GenerationPMTOR) .............................3 Parenting Through Change (PTC) ...................................................................................4 Purpose of Study ....................................................................................................................5 Research Questions ................................................................................................................7 Theoretical Perspectives Guiding the Study ..........................................................................9 Ecological Systems Theory of Development ................................................................... 9 Critical Multicultural Research Theory .........................................................................10 Methodological Approach ...................................................................................................11 Community Based Participatory Research ................................................................... 11 CHAPTER 2: LITERATURE REVIEW ...................................................................................12 Brief Overview..................................................................................................................... 12 Process of Change in Parent Training Interventions ............................................................13 Parent Management Training – the Oregon Model (GenerationPMTOR) .....................13 Parenting Through Change for Reunification (PTC-R) .........................................15 GenerationPMTO core components .......................................................................15 GenerationPMTO supportive components ............................................................ 16 Delivery of the intervention ................................................................................... 17 The study of change in GenerationPMTO .............................................................17 Holtrop, Parra-Cardona, and Forgatch (2014) process of change model ...........19 Health Disparities as a Barrier for Dissemination of PT Interventions .............................. 20 Discrimination ............................................................................................................... 20 Evidence Based Parenting Interventions with Ethnic Minority Families ............................21 Cultural adaptation .........................................................................................................21 Latinx families ...............................................................................................................22 Dissemination of efficacious PT interventions with Latinx populations ................23 Immigration and acculturation ...............................................................................26 African American families ..............................................................................................26 Dissemination of efficacious PT interventions with African American populations ..............................................................................................................27 Racial socialization..................................................................................................28 Intimate Partner Violence ....................................................................................................29 CHAPTER 3: METHOD ............................................................................................................32 Research Design....................................................................................................................32 viii Overview of approach ....................................................................................................32 Justification for the use of qualitative methods ..............................................................32 Thematic analysis ...........................................................................................................34 Role of the researcher .....................................................................................................35 Applying a CBPR Approach .................................................................................................36 Community Based Participatory Research (CBPR) .......................................................36 Background of the study ................................................................................................36 Design .............................................................................................................................37 Administration for Children’s Services (ACS) .........................................................38 Implementation ...............................................................................................................38 Dissemination of findings ..............................................................................................39 Overview of Participants and Implementation Site ..............................................................39 Recruitment .....................................................................................................................40 Inclusion and exclusion criteria ................................................................................41 Procedures .............................................................................................................................42 Recruitment of parents/primary caregivers .....................................................................42 Recruitment of interventionists .......................................................................................43 Participants ......................................................................................................................43 Parents/primary caregivers........................................................................................44 Interventionists ..........................................................................................................45 Data Collection .....................................................................................................................45 Overview of procedure ...................................................................................................45 Interviews with parents/primary caregivers ..............................................................46 Interviews with interventionists ...............................................................................47 Interview guides .......................................................................................................47 Modifications to the research questions ....................................................................47 Data management and preparation .................................................................................48 Note taking and journaling..............................................................................................48 Data Analysis .......................................................................................................................49 Overview ........................................................................................................................49 Qualitative computer software .......................................................................................50 Trustworthiness .....................................................................................................................50 Credibility ......................................................................................................................50 Dependability and confirmability ..................................................................................51 Transferability ................................................................................................................51 CHAPTER 4: RESULTS ............................................................................................................53 Cultural and Contextual Relevance of PTC-R: Participants’ Perspectives ..........................54 Empowerment through parenting: “Nobody’s born knowing how to be a parent.” .......54 Finding hope: “Not all is lost.” .......................................................................................55 Fostering a sense of community with other parents: “It set off a light bulb [in me].” ...55 Coping with separation and reintegration: “Reunification can be very tough.” .............56 Personal growth beyond parenting: “They taught us how to speak.” .............................57 Cultural and Contextual Relevance of PTC-R: Interventionists’ Perspectives ...................58 Adaptations aimed at increasing cultural and contextual relevance ...............................58 Engagement sessions ................................................................................................58 ix Bringing down barriers: Simplifying intervention materials ....................................59 Increasing contextual relevance ...............................................................................60 Relevance and Perceived Impact of GenerationPMTO Core Components ..........................61 Limit setting: Parents’ perspectives ................................................................................62 Limit setting: Interventionists’ perspectives ...................................................................63 Skills encouragement: Parents’ perspectives ..................................................................64 Token system ............................................................................................................65 Skills encouragement: Interventionists’ perspectives .....................................................65 Token system ............................................................................................................66 Positive involvement: Parents’ perspectives ...................................................................66 Positive involvement: Interventionists’ perspectives .....................................................67 Monitoring and supervision: Parents’ perspectives .......................................................68 Monitoring and supervision: Interventionists’ perspectives ...........................................68 Problem solving: Parents’ perspectives ..........................................................................69 Problem solving: Interventionists’ perspectives .............................................................69 Relevance and Perceived Impact of GenerationPMTO Supportive Components ................70 Emotional regulation: Parents’ perspectives ...................................................................70 Emotional regulation: Interventionists’ perspectives......................................................71 Active communication: Parents’ perspectives ................................................................72 Active communication: Interventionists’ perspectives ...................................................73 Good directions: Parents’ perspectives ...........................................................................73 Good directions: Interventionists’ perspectives ..............................................................74 Intervention Delivery Methods .............................................................................................74 Role-plays: Parents’ perspectives ...................................................................................74 Role-plays: Interventionists’ perspectives ......................................................................75 Home practice assignments: Parents’ perspectives.........................................................76 Home practice assignments: Interventionists’ perspectives ...........................................76 The Key Role of Interventionists ..........................................................................................77 Parents’ Perspectives on their Process of Change: Parenting Practices ...............................78 Attempt ...........................................................................................................................78 Appraise ..........................................................................................................................79 Apply...............................................................................................................................80 Intimate Partner Violence .....................................................................................................82 Additional Areas of Improvement: Increased Attention to Cultural and Contextual Issues 83 Participants’ perspectives................................................................................................83 Discrimination...........................................................................................................83 Immigration...............................................................................................................84 Cumulative trauma ....................................................................................................85 Interventionists’ perspectives..........................................................................................86 Language ...................................................................................................................86 Monitoring and supervision ......................................................................................87 Corporal punishment .................................................................................................87 Conflict resolution and problem solving...................................................................88 CHAPTER 5: DISCUSSION......................................................................................................89 The Prominence of Culture and Context ..............................................................................89 x ACS context ....................................................................................................................90 Parenting in context ........................................................................................................91 The role of social support ..............................................................................................91 Discrimination.................................................................................................................92 Findings according to ethnic self-identification .............................................................92 Intimate partner violence ................................................................................................93 Perceived Relevance of PTC-R Intervention ........................................................................94 Limit setting ....................................................................................................................94 Skills encouragement ......................................................................................................96 Positive involvement.......................................................................................................97 Monitoring and supervision ............................................................................................97 Problem solving ..............................................................................................................97 GenerationPMTO supportive components .....................................................................98 Intervention delivery methods ........................................................................................99 The key role of interventionists ....................................................................................100 Parents’ Process of Change .................................................................................................101 Study Limitations and Strengths .........................................................................................102 Implications for Research ...................................................................................................103 Implications for Family Therapy ........................................................................................106 Conclusion ..........................................................................................................................108 APPENDICES .........................................................................................................................109 APPENDIX A: Figure A.1: Holtrop et al.’s (2014) theory of change in GenerationPMTOR .............................................................................................................110 APPENDIX B: Table A.1: Culturally adapted evidence based parenting programs for Latinx populations .............................................................................................................111 APPENDIX C: PTC-R Parents’ Consent Form (English) .................................................115 APPENDIX D: PTC-R Parents’ Consent Form (Spanish) ................................................118 APPENDIX E: PTC-R Interventionists’ Consent Form ....................................................121 APPENDIX F: PTC-R Parents’ Interview Guide (English) ..............................................123 APPENDIX G: PTC-R Parents’ Interview Guide (Spanish) .............................................126 APPENDIX H: PTC-R Interventionists’ Interview Guide ................................................129 APPENDIX I: Study Demographics Form (English) ........................................................131 APPENDIX J: Study Demographics Form (Spanish) .......................................................132 REFERENCES ........................................................................................................................133 xi LIST OF TABLES Table 3.1: Demographic characteristics of parents/primary caregivers...................................... 44 Table 3.2: Note taking and journaling ........................................................................................ 49 Table 3.3: Phases of thematic analysis ....................................................................................... 49 Table A.1: Culturally adapted evidence based parenting programs for Latinx populations .... 111 xii LIST OF FIGURES Figure 4.1: Cultural and contextual relevance of the PTC-R intervention ............................... 53 Figure 4.2: Participants’ process of change and additional areas of improvement .................. 54 Figure A.1: Holtrop et al.’s (2014) theory of change in GenerationPMTOR .......................... 110 xiii CHAPTER 1: INTRODUCTION Statement of the Problem1 Child maltreatment constitutes a major public health problem in the United States (US). During the federal fiscal year 2014, child protective services documented a 14.6 percent increase in child maltreatment referrals compared to 2010. Of these referrals, 19.2% were confirmed cases of child abuse or neglect involving 6.6 million children, considering that a referral can include multiple children (US Department of Health and Human Services [DHHS], 2016). Developmental, emotional, behavioral, and cognitive problems are prevalent among children in the child welfare system/services (CWS; Casanueva, Dolan, Smith, Ringeisen, & Dowd, 2012; Casanueva et al., 2014). Foster care placement frequently introduces additional instability to a child’s already chaotic life (Casanueva et al., 2014 Wildeman & Emanuel, 2014), increasing their risk for deleterious physical and mental health outcomes (Harman, Childs, & Kelleher, 2000). It has also been documented that former foster care recipients are less likely to complete high school, are at a higher risk of experiencing homelessness and unemployment, and are more likely to become involved in the criminal justice system, when compared to the general child and youth population (Garcia, Pecora, Harachi, & Aisenberg, 2012; Southerland, Casanueva, & Ringeisen, 2009; Pecora et al., 2010). Although a large body of literature has focused on the child maltreatment population served by the CWS in general, significant gaps in research exist with regard to low-income and diverse populations required to complete mandatory treatment due to child maltreatment allegations (Harris et al., 2010). Specifically, there is a disproportionate representation of low- 1 “Latinx” is the gender-neutral term used throughout this document to refer to populations of Latin American origin and descent to promote inclusivity of intersecting identifies, including people who are trans, queer, non-binary, gender non-conforming, or gender fluid. 1 income ethnic minority children and youth in CWS. These families are likely to be exposed to severe contextual challenges such as poverty, health and mental health disparities, and various expressions of racial bias and discrimination (Hines, Lemon, Wyatt, & Merdinger, 2004; Jimenez & Chambers, 2009). Due to the multiple forms of adversity commonly experienced by ethnic minority families involved in CWS, it is highly relevant to examine the best strategies to improve their quality of life. For example, research has documented that African American youth who have access to high quality mental health services while in foster care, are more likely to complete high school or attain a General Educational Diploma (GED; Garcia et al., 2012). Parent Training Interventions as an Alternative to Address Child Maltreatment The US federal government has the mandate to ensure the safety and wellbeing of all children and youth in the nation, particularly those affected by child abuse and neglect (DHHS, 2016). A promising but still underdeveloped area of research refers to the dissemination of evidence-based parenting interventions among ethnic minority and underserved families, as an alternative to eliminate or prevent child maltreatment (Administration for Children and Families, 2012). An extensive body of literature indicates that efficacious Parent Training (PT) interventions can significantly reduce and prevent conduct problems among children and youth (Martinez & Eddy, 2005). PT interventions actively promote effective parenting skills, which are likely to positively influence overall child development and adaptation (Coard, Wallace, Stevenson, & Brotman, 2007; Forgatch & Patterson, 2010). Longitudinal data from rigorous randomized controlled trials indicate that PT interventions are associated with permanent improvements in child behavior, parental wellbeing, and overall family functioning (Forgatch, Patterson, DeGarmo & Beldavs, 2009; Michelson, Davenport, Dretzke, Barlow, & Day, 2013). Specifically, PT interventions have been found to 2 reduce child internalizing and externalizing behaviors (Forgatch et al., 2009), drug and alcohol use (Martinez & Eddy, 2005; Petrie, Bunn, &Byrne, 2007), and positively impact child health and mental health outcomes (West, Sanders, Cleghorn, & Davies, 2010). A limited number of large-scale and rigorous trials have been implemented to study the impact of these interventions with families involved in the child welfare system. Findings from existing studies are extremely promising, as they indicate the successful elimination of child maltreatment, improvement in parenting practices, and successful parent-child reunification (Chamberlain, Wolf Feldman, Wulczyn, Saldana, & Forgatch, 2016). However, limited empirical data exist focused on understanding the process of change in parenting practices and family functioning as families are exposed to efficacious PT interventions. In particular, the qualitative empirical literature focused on the experiences of lowincome ethnic minority parents involved in CWS remains extremely limited. Thus, it is necessary to understand the adaptations that are needed to implement original interventions to increase their contextual and cultural relevance. Further, scarce research exists documenting key factors that are likely to negatively impact the implementation of PT interventions. For example, the parenting literature is characterized by limited attention to issues of intimate partner violence and controlling behaviors by men. Promoting these lines of research is highly relevant in order to address existing service barriers within the CWS, particularly focusing on the needs of low income-families of color (Harris, Jackson, O’Brien, & Pecora, 2010; Hines et al., 2004; Garcia et al., 2012). Parent Management Training – the Oregon Model (GenerationPMTOR) Parent Management Training – the Oregon Model (GenerationPMTOR) is an evidencebased clinical and preventative PT intervention for families with children exhibiting mild to 3 severe behavioral problems (Forgatch et al., 2009). GenerationPMTO was developed according to a theoretical foundation grounded in the premise that effective parenting practices are essential precursors for improving the quality of parent-child relationships and child outcomes (Patterson, Forgatch, & DeGarmo, 2010). The intervention has been implemented in a variety of program formats targeting multiple clinical populations (Forgatch & Patterson, 2010). Recent research has provided evidence of the positive impacts of the interventions with Latinx populations in the US (Domenech-Rodriguez et al., 2013; Parra-Cardona et al., 2017), Mexico (Baumann, DomenechRodriguez, Amador, Forgatch, & Parra-Cardona, 2014), Uganda (Wieling et al., 2015), and ethnic minority refugee populations in Norway (Bjørknes, Kjøbli, Manger, & Jakobsen, 2012). Parenting Through Change (PTC). Parenting Through Change (PTC) is a group-based version of the original GenerationPMTO intervention for parents whose children are living at home. The PTC intervention has a detailed manual that has been empirically tested in several randomized controlled trials (Forgatch et al., 2009; Forgatch & DeGarmo, 1999). Findings from these studies have demonstrated positive parenting and child outcomes for serious child behavioral problems, resulting in decreased involvement in the child welfare system (Forgatch, Patterson, & Gewirtz, 2013). Parenting Through Change for Reunification (PTC-R) was developed based on the PTC curriculum and targets biological and adoptive parents with children in foster care (Chamberlain et al., 2016). The PTC-R program consists of 10 weekly 90minute sessions. Ideally, PTC-R is complemented by PTC-Return Home (PTC-RH), a 6-week parenting group designed for parents who have completed the PTC-R intervention and are at the juncture of reunification with their children. The PTC-RH can be understood as a booster program aimed at reinforcing the topics and skills addressed in the PTC-R program, with an emphasis on post-reunification issues (e.g., monitoring and supervision, promoting school 4 success). Unfortunately, due to various implementation challenges, not all parents who complete the PTC-R program can engage in the PTC-RH intervention (A. Muñoz, personal communication, February 26, 2016). For that reason, this investigation focused exclusively on parents who completed the PTC-R intervention with certified interventionists in the model. Purpose of Study Ethnic minority populations in the US are exposed to widespread mental health disparities that prevent them from engaging in high quality mental health services (DHHS, 2001). In addition, low-income ethnic minority families are more likely to experience unique contextual challenges such as poverty, racial discrimination, community violence, and limited access to health care and education (Alegria, Atkins, Farmer, Slaton, & Stelk, 2010). Although ethnic minority children are overrepresented in the CWS (Hines et al., 2004), there is limited empirical literature documenting their experiences as recipients of culturally relevant and efficacious PT interventions within the system (Chamberlain et al., 2016; Garcia et al., 2012). Thus, this investigation was designed to explore the cultural relevance of the PTC-R intervention and examine the process of change experienced by a group of low-income ethnic-minority parents involved in the CWS, and who were exposed to the PTC-R intervention as a requisite for reunification with their children. Multiple research aims were accomplished in this investigation. First, the study focused on exploring how the content of the PTC-R program, method of delivery, and adaptations by interventionists facilitated, or impeded, the process of change experienced by participant families. To enhance the quality of the data, perspectives were gathered from parents exposed to the intervention and interventionists. Further, the role of the co-parenting relationship was explored to better understand its impact on parents’ participation in the parenting program. In addition to 5 co-parenting issues, dynamics of power and control and intimate partner violence, if reported, were explored. Finally, because this study followed the tenets of community-based participatory research (CBPR), key areas of exploration that were of high interest to research collaborators were examined. For example, agency leaders were interested in learning about the ways in which exposure to the parenting intervention impacted parents’ relationships with their immediate social support networks. To accomplish the research aims, individual interviews were conducted with a sample of 14 parents who successfully completed the PTC-R program. Data were complemented with interviews of 8 certified PTC-R interventionists, focused on the topics of interest. At the time of screening, all families had to be reunified with their children and no longer remain as active child welfare cases. A thematic analysis approach was used to collect, analyze, and interpret the data (Braun & Clarke, 2006; 2012). Holtrop, Parra-Cardona, and Forgatch’s (2014) model of change was used to guide this investigation in regards to the examination of parental process of change related to parenting practices (see Figure 3.1, Appendix A). Briefly, Holtrop and colleagues’ model of change emerged from a qualitative investigation aimed at describing the process of change associated with the GenerationPMTO intervention. One of the key limitations of the original model refers to the fact that it was developed with a sample of Euro-American parents. Thus, the model was used as an initial guide for this investigation, but the design was fully adapted according to the goals of the study and the context of implementation of the PTC-R intervention. The current investigation constitutes a relevant contribution to the field as there is a limited number of qualitative studies focused on examining the experiences and process of change for low-income ethnic minority parents who have been exposed to an efficacious PT 6 intervention (Holtrop et al., 2014). This is particularly the case for ethnic minority families involved in CWS (La Greca, Silverman, & Lochman, 2009). In addition, it is essential to reach a better understanding of the impact that key experiences have on families participating in PT interventions, such as coercive control and intimate partner violence (Jouriles & McDonald, 2015; Unger, 2015). Research Questions Two sets of research questions guided this investigation2. The questions pertaining to parents were: 1. What is the process through which participants’ experiences in the PTC-R intervention led to changes in their parenting practices? Specifically, parents were asked to provide their perceptions regarding: (a) How did the content of the PTC-R intervention facilitate or impede the parents’ process of change? (b) How did the method of delivery of the PTC-R intervention facilitate or impede the parents’ process of change? (c) How did cultural adaptations implemented by interventionists facilitate or impede the parents’ process of change? 2. How did the co-parenting relationship influence the participants’ engagement in the PTC-R intervention, as well as acquisition of new parenting skills? 2 Questions 1c and 2a were eliminated from the original research questions as they were not worded appropriately and were irrelevant to participants. Upon approval from the dissertation committee, the content areas related to these questions were explored via alternative inquiries. For example, rather than asking parents about characteristics of “cultural adaptation” related areas such as satisfaction with method of delivery were assessed, which constitutes a key dimension of cultural adaptation. 7 (a) If power and control issues or intimate partner violence were reported by participants and/or identified by interventionists, how did these experiences influence the participants’ experience in the intervention? 3. How did exposure to the parenting intervention impact the participants’ non-familial interpersonal relationships? 4. How did exposure to the parenting intervention impact the participants’ coping and life skills? 5. To what extent did participants consider that the PTC-R intervention adequately addressed their parenting experiences as low-income and ethnic minorities? The questions pertaining to the interventionists were: 1. What is the process of change that interventionists consider led to participants’ changes of their parenting practices? Specifically, interventionists were asked to provide their perceptions regarding: (a) How did the content of the PTC-R intervention facilitate or impede the parents’ process of change? (b) How did the method of delivery of the PTC-R intervention facilitate or impede the parents’ process of change? 2. What cultural adaptations did interventionists implement to increase the contextual and cultural relevance of the PTC-R intervention? 3. How did the interventionists address issues of coercive control or intimate partner violence, whenever they were identified in families exposed to the PTC-R intervention? 8 Theoretical Perspectives Guiding the Study Two main theoretical perspectives guided this investigation. The Ecological Systems Theory of Development (Brofenbrenner, 1986) provided an overarching framework for understanding the multiple contexts influencing the lives of low-income ethnic minority parents involved in the child welfare system. In addition, Critical Multicultural Research Theory (McDowell & Fang, 2007) informed the conceptualization of this study based on the focus given to societal and individual power imbalances, according to multiple identities such as race, ethnicity, gender, socioeconomic status, and immigration status, among others. Ecological Systems Theory of Development. Bronfenbrenner (1986) described the process of human development and behavior as embedded within multiple systems, cultures, and contexts. Bronfenbrenner conceptualized five different systems in which individuals exist: the microsystem, mesosystem, exosystem, macrosystem, and chronosystem. Each of these systems are interrelated and interdependent. This framework is useful for understanding multiple societal and political influences impacting the lives of individuals and families (White & Klein, 2008). For instance, to understand the experiences of low-income ethnic minority parents involved in the CWS, it is essential to consider the multiple socio-political and economic contexts and factors that have a detrimental effect on the parenting practices. The Microsystem consists of the immediate systems in an individual’s life. For parents participating in this study, these may include their relationships with their children, caseworkers, and social support networks. The Mesosystem refers to the interactions between microsystems: for example, the interaction between a child’s foster family and the child welfare services, as parents seek to obtain reunification. The Exosystem consists of those systems that have an indirect influence on the individual. For instance, if caseworkers are engaged with agency 9 directors and funders who view parents as resilient, caseworkers are likely be positively influenced by such positive perceptions of the families. The Macrosystem refers to the political and social contexts in which individuals live. For low-income ethnic minority parents, the macrosystem involves a society that privileges White and middle class values and experiences. Finally, the Chronosystem refers to the role of time on human development. For example, local and national policies have an impact on organizations and institutions mandated to serve specific populations, such as diverse families involved in the child welfare system. Critical Multicultural Research Theory. Critical Multicultural Research (CMR) Theory provides a theoretical framework to conduct research and generate knowledge by highlighting the significance of social, historical, and cultural contexts in which families live. This framework provides a way to critically analyze societal and political power imbalances by drawing attention to experiences of oppression, as well as identifying how societal structures may promote and sustain power inequities between individuals, families, and minority groups. One of the main goals of CRM is to connect participants’ experiences with sociopolitical structures in an effort to create a more inclusive understanding of diverse families (McDowell & Fang, 2007). CMR premises were useful for the conceptualization of this study as they framed the investigation according to the assumptions that dynamics among families and social systems are reciprocal (McDowell & Fang, 2007). That is, the experiences of oppressed individuals must be understood within the contexts in which they occur. For example, parents involved in CWS can be labeled as neglectful, uncaring, and even abusive towards their children. However, if experiences of discrimination, institutional racism, and poverty are taken into consideration, alternative explanations can be generated with regards to neglectful parenting, as well as the 10 resources parents need to engage in a process of change. The CMR theory is relevant to this investigation because the current study aimed to highlight participants’ experiences within the “larger social discourse for competing knowledges” (McDowell & Fang, 2007, pp. 553). Methodological Approach Community Based Participatory Research. A community based participatory research (CBPR) framework guided this investigation. Following the tenets of CBPR, community leaders and representatives were included throughout the study as close research partners (Israel, Schulz, Parker, & Becker, 1998). Specifically, collaborative relationships were established with key community partners, such as PTC-R interventionists, supervisors, and agency administrators. This partnership guided all aspects of this investigation, including the negotiation of research questions, development of interview guides, manuscript elaboration, and dissemination of findings. To establish this trusting relationship, conference calls were routinely scheduled to discuss and develop the current research study. CBPR is to be conducted in a way that explicitly acknowledges the strengths and resources that the target community can contribute towards research and co-creation of knowledge (Israel et al., 2003). Because this study was designed with the purpose of generating knowledge aimed at benefiting underserved ethnic minority families, a CBPR approach informed all phases of the research process to ensure that the participants’ experiences were well understood, valued, and communicated (Israel et al., 1998). 11 CHAPTER 2: LITERATURE REVIEW Brief Overview Numerous studies indicate that children involved in the child welfare system (CWS) are at a high risk for deleterious developmental, emotional, and behavioral outcomes (Casanueva et al., 2012; Garcia et al., 2012; Herman, Childs, & Kelleher, 2000; Pecora et al., 2010). Parent Training (PT) interventions have been thoroughly recognized as effective alternatives for treating and preventing behavioral problems in children and youth (Forgatch et al., 2009, Forgatch & Kjøbli, 2016, Martinez & Eddy, 2005; Petrie et al., 2007). However, although an extensive body of literature has confirmed the efficacy of PT interventions, there is limited literature documenting the experiences of low-income ethnic minority families after exposure to this type of intervention (Alegria et al., 2010; Cook & Manning, 2009; DHHS, 2001; Mejia et al., 2012). Further, there is a significant gap in research concerning the mechanisms of change associated with PT interventions, particularly with regard to parenting programs disseminated in challenging contexts and with hard-to-reach populations (Sandler, Schoenfelder, Wolchik, & MacKinnon, 2011). Researchers and funding agencies have also increasingly highlighted the need to examine how mechanisms of change are promoted in efficacious parenting interventions, while also recognizing the influence of key cultural and contextual factors that impact the lives of diverse families (Kotchick & Forehand, 2002). In addition, an important issue that is often overlooked in PT interventions refers to the impact of power dynamics on the couple and coparenting relationship, as well as coercive control and intimate partner violence (IPV; Bancroft & Silverman, 2002). Examining how these issues impact the delivery of efficacious PT interventions constitutes a research priority, particularly when considering the detrimental emotional, behavioral, and developmental effects of children’s exposure to IPV (Rossman, 2001). 12 In the sections below, a review of the literature focused on key areas of research relevant to this investigation is presented. First, a brief overview of the literature focused on the process of change literature in PT interventions is described, complemented by a description of the GenerationPMTO intervention. Next, a summary of the literature on culturally adapted efficacious PT interventions for Latinx and African American populations is included. Finally, a discussion highlighting the importance of addressing IPV issues in the delivery of PT interventions is presented. Process of Change in Parent Training Interventions The study of process of change associated with efficacious PT interventions is essential to understand underlying mechanisms leading to expected intervention outcomes (Kazdin, 2005; Kazdin & Nock, 2003). It is relevant to increase the understanding of mechanisms of change associated with PT interventions, particularly as these interventions are disseminated in community agencies serving low-income populations (Gardner, Burton, & Klimes, 2006; Mejia, Ulph, & Calam, 2016). Further, studying the mechanisms of change in PT interventions can also help researchers identify the essential core components of these interventions to ensure that components accounting for efficacy retained in culturally adapted interventions for diverse populations (Bernal, Jimenez-Chafey, & Domenech-Rodriguez, 2009). Parent Management Training – the Oregon Model (GenerationPMTOR). GenerationPMTO constitutes an evidence-based parenting intervention for which efficacy and effectiveness have been demonstrated in multiple trials, contexts, cultures, and formats (Forgatch & Kjøbli, 2016). GenerationPMTO studies indicate that sustained outcomes of the intervention include positive changes in parenting skills, improved child outcomes, and decreased involvement in the child welfare services (Forgatch, Patterson, & Gewirtz, 2013). The 13 intervention is grounded in the social interaction learning theory (SIL), which postulates that coercion processes negatively impact child development and the quality of parent-child relationships (Forgatch & Domenech-Rodriguez, 2016; Forgatch & Patterson, 2010; Patterson, Forgatch, & DeGarmo, 2010). Briefly, coercion processes refer to negative cycles of escalation, negative reciprocity, and reinforcement. For example, if a parent gives a command to a child, the child may throw a tantrum. In response, the parent may experience frustration, engage in escalating behaviors such as yelling or spanking, or withdraw from the interaction altogether. If these patterns are repeated over time, parents may reduce their involvement in limit setting activities, leading to a pattern of increased child aversive behaviors whenever rules are implemented (Forgatch & Domenech-Rodriguez, 2016). Empirical research indicates that coercive processes are notoriously prevalent in families with children and youth exhibiting a wide array of externalizing behaviors (Forgatch, Beldavs, Patterson, & DeGarmo, 2008). In contrast, according to SIL premises, parents can positively influence the development of their children by using behavior modeling and effective parenting practices (Forgatch & Martinez, 1999). The SIL theory posits that behavior is shaped during repeated social interactions with significant individuals (Forgatch & Kjøbli, 2016). Thus, effective parenting practices are identified as key mechanisms of change, leading to positive adjustments for children and adolescents (Forgatch, DeGarmo, & Beldavs, 2005). Grounded in a mediational model, it is expected that by strengthening positive parenting behaviors, child outcomes will be positively impacted (Forgatch & Patterson, 2010). Findings from clinical and prevention GenerationPMTO trials have confirmed that reducing coercive interactions within families and replacing them with positive parenting practices promotes healthy adjustment not only for children, but also for parents (Forgatch & 14 Domenech Rodriguez, 2016; Forgatch & Martinez, 1999; Forgatch & Patterson, 2010). According to the model, interventionists work directly with parents to help them replace coercive parenting strategies with parenting skills that promote pro-social behaviors (Forgatch & Domenech-Rodriguez, 2016). Various versions of the intervention have been found to be efficacious with families with children raging from preschool age to adolescence. Moreover, these interventions have been successfully delivered in individual format, in-home, parent groups, and online (Forgatch & Kjøbli, 2016). Positive long-term outcomes have been documented in a longitudinal study with outcomes lasting over a 9-year period post intervention (Forgatch et al., 2009). GenerationPMTO has been designated as an evidence-based program for treating internalizing and externalizing disorders, delinquency, academic functioning, and child noncompliance (SAMHSA, 2011). Parenting Through Change for Reunification (PTC-R). Parenting Through Change for Reunification (PTC-R) is a group-based version of the GenerationPMTO, specifically designed for biological and adoptive parents who have a child placed in foster care. The parenting intervention is delivered in a group format, with the provision of complementary individual mental health services to address additional problems such as parental depression (Chamberlain et al., 2016). The PTC-R intervention has a detailed manual that has been adapted for this population. Therefore, home practice assignments are tailored for times when parents have visitations with their children. Interventionists also encourage parents to practice these skills with other family members, neighbors, and/or coworkers (A. Muñoz, personal communication, April 2016). GenerationPMTO core components. The original GenerationPMTO intervention consists of five core components, which are also included in the PTC-R intervention. The core 15 components are: (a) skills encouragement, (b) positive involvement, (c) limit setting, (d) monitoring and supervision, and (e) problem solving (Forgatch et al., 2009). The first core component, skills encouragement, refers to promoting the use of positive reinforcement and scaffolding techniques to teach children complex behaviors. Parents are taught to use reinforcers, such as incentive charts and tokens, to develop and strengthen behavioral skills (Forgatch & Patterson, 2010). Positive involvement assists parents with skills aimed at strengthening the parent-child emotional bond, including teaching parents the importance of warm and attentive interactions (Forgatch & Martinez, 1999; Forgatch & Patterson, 2010). The third core component, limit setting, offers parents strategies consisting of the use of mild consequences to establish appropriate and consistent boundaries for child misbehavior. Parents are presented with the use of structured time out procedures and work chores as limit setting strategies. Privilege removal is used as a backup strategy for non-compliance (Forgatch & Patterson, 2010). The fourth component, problem solving, offers strategies to parents for working together as a family, manage disagreements, and plan joint activities to increase family cohesion (Forgatch & Martinez, 1999; Forgatch & Patterson, 2010). Finally, monitoring and supervision involves teaching effective supervisory techniques to parents to track the whereabouts of their children and ensure their children’s safety (Forgatch & Patterson, 2010). GenerationPMTO supportive components. A set of supportive components strengthens the delivery of the intervention’s core components (Forgatch & Patterson, 2010). These include: (a) good directions, (b) emotion regulation, and (c) active communication. Good directions refers to teaching parents how to give short, simple, and clear commands for children to achieve specific behavioral tasks (Forgatch & Patterson, 2010). Emotional regulation refers to teaching parents skills to recognize and effectively manage their emotions when engaging in challenging 16 parenting situations (Forgatch & Domenech-Rodriguez, 2016). Finally, active communication assists parents with active listening strategies that stimulate open communication and expression among family members (Forgatch & Domenech-Rodriguez, 2016). Additional supportive components may be included to address specific issues having an influence on families such as cultural values and traditions, traumatic experiences, immigration issues, academic problems, or family structure transitions (Forgatch & Kjøbli, 2016). Delivery of the intervention. Parents participate in GenerationPMTO interventions in weekly individual sessions or parent group sessions. Sessions typically last 60-90 minutes and follow a structured combination of reviewing and troubleshooting previous skills, active learning of new material, and preparation for home practice assignments (Forgatch & Patterson, 2010). One of the key aspects that distinguishes GenerationPMTO from other PT interventions consists of its emphasis on active learning. Specifically, the intervention includes a variety of active teaching strategies such as the use of role-plays, which are utilized to practice skills with interventionists, prior to real implementation with their children. Role-plays follow a sequential step-by-step approach. For example, role-plays are commonly used to teach parents the time-out sequence by rehearsing various levels of difficulty in the parent-child interaction (Forgatch & Domenech Rodriguez, 2016). Participants also learn by completing home practice assignments designed to encourage parents to practice skills taught in the session. Sessions always begin with a review of these assignments, as parents are encouraged to discuss their experiences and problem-solve any challenges they may have experienced (Forgatch & Patterson, 2010; Knutson et al., 2009). The study of change in GenerationPMTO. To date, the study of how change occurs through PT interventions has centered on examining intervention mechanisms through 17 mediational analyses, as it is hypothesized that modifications in parenting practices will affect child behavioral outcomes (Gardner et al., 2006; Weersing & Weisz, 2002). Multiple studies of PT interventions have established empirical support for the mediating effects of parenting practices on child outcomes (Eddy & Chamberlain, 2000; Forgatch et al., 2009; Forgatch et al., 2016; Gardner et al., 2006). However, there is limited qualitative data indicating the caregivers’ level of satisfaction with specific parenting practices, as well as those most preferred by parents. The empirical research supporting GenerationPMTO has indicated that improvements in parenting practices mediate improvement in child outcomes (e.g., Bjørknes, Kjøbli, Manger, & Jakobsen, 2012; Forgatch et al., 2009). In the existing GenerationPMTO mediational models, exposure to the intervention is associated with reduction in coercive parenting practices, increased positive parenting, reduction of deviant peer association, and increased positive child outcomes (Forgatch et al., 2016; Forgatch & Kjøbli, 2016; Patterson, Forgatch, & DeGarmo, 2010). In a recent meta-analysis of PT interventions, researchers found that only 25 studies included evaluations of mediation effects of parenting practices on child outcomes. Interestingly, GenerationPMTO was identified as the intervention with the most robust empirical support, identifying parenting practices as the key mediator for change in child outcomes. (Forehand, Lafko, Parent, & Burt, 2014). Although there is a vast quantitative literature describing GenerationPMTO and its associated mechanisms of change, there is a dearth of qualitative research aimed at exploring parents’ perceptions of the intervention components that they consider to be most relevant to their parenting practices (Holtrop et al., 2014). Promoting this line of research in real-world settings and with underserved ethnic minority populations is essential to expand the impact of PT interventions in real world contexts (LaGreca, et al., 2009). 18 Holtrop, Parra-Cardona, and Forgatch (2014) process of change model. The model developed by Holtrop and colleagues emerged from a qualitative study aimed at strengthening the current knowledge base focused on the process of change associated with the GenerationPMTO intervention. Research participants reported that changes in their parenting practices led to perceived improvements in themselves, their children, and their family relationships. According to parents, the process of change was gradual and differential. That is, parents first attempted the new parenting skills as presented in the intervention and appraised their usefulness. Based on this initial examination, they proceeded to apply the GenerationPMTO parenting skills in various contexts and situations. As a result, parents followed distinctive trajectories. That is, some retained the newly learned parenting skills as presented, some adapted them to their contexts, others used them only when relevant, and a final group of parents set them aside as they did not find them relevant to their parenting practices. Overall, parents who kept utilizing or adapting the intervention skills reported that this process consisted of several gradual attempts over time. Ensuring contextual relevance was also of crucial importance to these parents. Interestingly, skills encouragement and limit setting were identified as particularly relevant core components. Clear directions and emotional regulation were also identified as highly useful, even more so than other core components (i.e., positive involvement, monitoring and supervision, problem solving). Further, participants highlighted the usefulness of various methods of delivery that allowed them to practice the parenting skills in a variety of daily childrearing activities. Specifically, parents identified the usefulness of role-plays, home practice assignments, and troubleshooting. The role of the facilitator was also identified as central to promoting growth in parenting practices. Although this study provided relevant information 19 about mechanisms of change, its major limitation consisted of its sampling design, as all participants were of Euro-American descent. The model is illustrated in Figure A.1 (Appendix A). Health Disparities as a Barrier for Dissemination of PT Interventions Despite the multiple benefits associated with evidence-based PT interventions, lowincome ethnic minority families have limited access to these programs (Alegría et al., 2012). Contextual barriers are critical to this phenomenon as ethnic minority populations in the US are at an increased risk for experiencing chronic contextual stressors such as poverty, community violence, and discrimination (CDC, 2005; Wilkins et al., 2012). In general, members of ethnic minorities are underprivileged and have less access to high quality health and mental health services than their non-Latinx Euro-American counterparts, even after adjusting for differences in education level and health needs (Alegría et al.2012, Cabassa, Zayas, & Hansen, 2006; Cook & Manning, 2009; IOM, 2009). Discrimination. In addition to structural barriers, health disparities researchers have challenged the prevention field to more overtly address discrimination as a key barrier for ethnic minorities accessing efficacious mental health services (Domenech-Rodriguez & Wieling, 2004; Kotchick & Forehand, 2002; Unger, 2015). These scholars indicate the need to inform efficacious interventions according to an awareness of the ways in which ethnic minority groups are often exposed to experiences of discrimination, harassment, and exclusion (Ayon, 2013; Beach et al., 2016; Cammack et al., 2011; Rastogi et al., 2012; Sue et al., 2007). As a result, ethnic minority families are significantly less likely to access quality health and mental health services (Baker et al., 2011). Further, discrimination can be directly linked to negative outcomes. For example, Bogart et al. (2013) found that perceived racial and ethnic discrimination was 20 associated with greater externalizing behaviors among Black and Latinx youth, such as increased substance use. Experiencing discrimination has also been linked to numerous adverse health outcomes, including depression, anxiety, and lower health-related quality of life (see Unger, 2015). The growing body of literature on evidence-based PT interventions suggests that interventions tailored for ethnic minority parents can be feasible and efficacious, while also being characterized by high contextual and cultural relevance (McCabe et al., 2012; Ortiz & Del Vecchio, 2013, Parra-Cardona et al., 2012). Evidence Based Parenting Interventions with Ethnic Minority Families The primary goal of this investigation consisted of exploring the experiences of a group of low-income and ethnic minority parents after participation in the PTC-R intervention. Given the target samples in this study, the current review will focus on Latinx and African American populations. Cultural adaptation. Cultural adaptation is defined as “the systematic modification of an evidence-based treatment (EBT) or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values” (Bernal et al., 2009, p.362). A recent meta-analysis of 78 studies evaluating culturally adapted interventions confirmed the positive effects associated with culturally adapted interventions (Hall, Ibaraki, Huang, Marti, & Stice, 2016). A previous meta-analytic study including 65 investigations, reported similar findings (Smith, Domenech Rodriguez, & Bernal, 2011). Various factors are hypothesized to be associated with these findings, such as increased retention and intervention dosage (Domenech Rodriguez, Baumann, & Schwartz, 2011; Kumpfer, Alvarado, Smith, & Bellamy, 2002). 21 A debate regarding the relevance of culturally adapting EBTs for dissemination with minority populations still exists (Bernal et al., 2009; Castro, Barrera, & Steiker, 2010; Kazdin & Wassell, 2000). Some scholars have called for the creation of new treatments developed specifically for various ethno-cultural groups (Comas-Diaz, 2006), whereas others have stated their concerns about compromising the integrity of original EBTs (Elliot & Mihalic, 2004). These researchers propose implementing EBTs with limited or no modifications at all (Chambless & Ollendick, 2001). As an alternative to these opposing views, cultural adaptation scholars have advocated for a balance between fidelity and fit (Castro, Barrera, & Martinez, 2004). Adaptations to original EBTs should increase cultural relevance while maintaining fidelity to the original core components of efficacious interventions. In essence, this stance consists of achieving implementation feasibility, intervention efficacy, and cultural relevance (Kumpfer, Magalhães, & Xie, 2012). Castro et al. (2004) have highlighted the need to move beyond conducting exclusively surface-level adaptations, by also implementing deep structure cultural adaptations. Surface-level adaptations refer to matching intervention materials to the observable characteristics of the target population in order to improve cultural fit. These adaptations may involve translating the content of the intervention or changing the appearance of role models in intervention materials. Although useful, surface-level adaptations are limited in scope. In contrast, deep structure adaptations refer to carefully adapting EBTs according to the most relevant cultural beliefs, norms, and values of the target populations. Deep structure adaptations require a keen understanding of the target population’s context and cultural experiences, and their influence on target outcomes (Resnikow, Soler, Braithwait, Ahluwalia, & Butler, 2000). 22 Latinx families. Latinxs currently account for 17.6% of the total US population and are identified as the largest ethnic minority group in the nation (US Census Bureau, 2016), However, this population continues to be seriously underserved and underrepresented in research and service delivery (Alegría, Mulvaney-Day, Woo, Virruell-Fuentes, 2012; Baker, Arnold, & Meagher, 2011). Low-income and immigrant Latinxs in the US are often at increased risk of experiencing discrimination and structural barriers when seeking health and mental health services (Ayon, 2013; Rastogi, Massey-Hastings, & Wieling, 2012). Access to high quality mental health care is further complicated when considering that low-income Latinx families are frequently exposed to greater levels of poverty, cumulative trauma, community violence, and discrimination than their non-Latinx Euro-American counterparts (Alegria et al., 2010; Mejia et al., 2012; Wight, Thampi, & Chau, 2011). The multiple contextual challenges experienced by Latinxs in the US can significantly disrupt parenting practices in Latinx families and increase children and youth risk for experiencing adjustment problems, internalizing and externalizing behaviors, and school dropout (Bámaca-Colbert, Umaña-Taylor, & Gayles, 2012; Estrada-Martinez, Padilla, Caldwell, & Schulz, 2011; Martinez, DeGarmo, & Eddy, 2004; National Institute on Drug Abuse [NIDA], 2007). Given the numerous and significant barriers and stressors facing underserved Latinx families in the US (Ayon, 2013; Mejia, Calam, & Sanders, 2015b), there is a high need for culturally relevant interventions capable of strengthening the protective factors of these families, as well as supporting the development of Latinx children and youth (Barrera, Castro, Strycker, & Toobert, 2013; Caldas de Almeida & Horvitz-Lennoi, 2010; Castro et al., 2004). Dissemination of efficacious PT interventions with Latinx populations. Table A.1 (Appendix B) provides a summary of existing cultural adaptation studies with PT interventions 23 for Latinx populations. Briefly, although studies of culturally adapted PT interventions implemented with Latinx populations remain limited, existing research suggests that culturally adapted programs contribute to positive outcomes among Latinx children and youth (Barker, Cook, & Borrego, 2010; Parsai, Marsiglia, & Kulis, 2010; Parra-Cardona et al., 2017; Prado et al., 2007). Given the heterogeneity among Latinx sub-populations, positive findings from trials testing culturally adapted evidence-based PT interventions with different Latinx samples are encouraging, as they demonstrate improvement of parenting skills and child outcomes (Rivera et al., 2008; Zayas, Borrego, & Domenech Rodriguez, 2009). Researchers have reported positive outcomes related to implementation feasibility (i.e., high retention rates and participant satisfaction), cultural acceptability, and efficacy (Dumas, Arriaga, Begle, & Longoria, 2011; Martinez & Eddy, 2005; Matos, Bauermeister, & Bernal, 2009; McCabe, Yeh, Lau, & Argote, 2012; Mejia, Calam, & Sanders, 2015a; Parra-Cardona et al., 2012). Although there is variability in the level of adaptation of existing interventions (i.e., surface vs deep structure), overall findings suggest that cultural adaptations enhance the impact of the PT interventions and their associated core components on parenting and child outcomes (McCabe et al., 2012). For example, Guiando a Niños Activos (GANA) is a culturally adapted version of Parent-Child Interaction Therapy (PCIT), an empirically supported treatment developed for families with young children who experience behavior problems (Eyberg, Nelson, & Boggs, 2008). Cultural adaptations of the program involved a series of surface-level and deep structure adaptations that tailored the delivery of the program to optimize cultural fit. A randomized controlled trial (RCT) aimed at comparing the effectiveness of GANA to a standard version of PCIT with Mexican American parents found that both PCIT and GANA produced 24 outcomes that were maintained over time. However, the GANA interventions produced more robust and lasting effects than PCIT on child internalizing symptoms (McCabe et al., 2012). Similarly, Criando con Amor Promoviendo Armonía y Superación (CAPAS) is a culturally adapted version of GenerationPMTO for Latinx families originally adapted by Domenech Rodríguez and colleagues (2011). The initial examination of CAPAS with a sample of Latinx immigrants produced satisfaction and retention rates similar to other GenerationPMTO intervention trials with non-Latinx populations (Domenech Rodriguez et al., 2011). The CAPAS intervention has been used to compare differential feasibility and efficacy in research with Latinx populations. For example, Parra-Cardona et al. (2017) compared and contrasted the original CAPAS intervention with a culturally enhanced version that integrated culturally focused themes (e.g., immigration, biculturalism), as well as increased cultural and contextual tailoring of all intervention components. Implementation feasibility data indicated high retention rates and participant satisfaction with both adapted interventions. Specifically, parents in both interventions reported significant improvement on parenting practices when compared to the control condition, without statistically significant differences between intervention conditions. The most robust improvements on child outcomes were identified in the culturally enhanced intervention, with fathers reporting the most significant improvements in child externalizing behaviors (Parra-Cardona et al., 2017). This differential study indicated that, although adaptations to ensure cultural and contextual relevance of the core GenerationPMTO components were highly beneficial in both adapted interventions, the culturally enhanced intervention appeared to have an incremental effect based on its additional focus on specific contextual and cultural factors. 25 Immigration and acculturation. Targeting contextual and cultural factors that are likely to increase intervention efficacy among Latinx populations represents a relevant and promising direction to advance the scholarship on evidence-based PT interventions with Latinx populations (Baumann et al., 2011). Therefore, various culturally adapted PT interventions for Latinxs have a focus on addressing immigration related stressors and conflicts, such as the acculturation gap that may exist between Latinx parents and their children (Smokowski, Rose, & Bacallao, 2008). Researchers have focused on these themes due to significant associations between acculturation challenges and behavior problems in Latinx youth (Chavez-Korell et al., 2014; Prado, Szapocznik, Maldonado-Molina, Schwartz, & Pantin, 2008; Schwartz et al., 2013). Further, culturally-focused interventions aimed at promoting biculturalism among Latinx families have been found to be effective for preventing internalizing and externalizing behaviors in youth (Carpentier et al., 2007; Coatsworth, Pantin, & Szapocznik, 2002; Cordova, Huang, Pantin, & Prado, 2012; Gonzales et al., 2012). In light of this data, developmental researchers have continued to challenge applied scholars by highlighting the need to more clearly specify the mechanisms of change associated with PT interventions, particularly as it refers to the influence of contextual and cultural variables (Calzada, 2010). African American families. African Americans in the US have experienced multigenerational oppression, discrimination, and exclusion. These experiences have resulted in widespread health and mental health disparities (Wilkins, Whiting, Watson, Russon, & Moncrief, 2012). For many health conditions, African Americans are disproportionately burdened by disease, death, and disability in contrast to other ethnic groups (Centers for Disease Control and Prevention [CDC], 2005). African Americans are also often confronted with chronic contextual stressors such as poverty, exposure to community violence, racial profiling, and widespread 26 discrimination (Beach et al., 2016; Cammack, Lambert, & Ialongo, 2011). Studies have corroborated that African American youth living in impoverished communities are at a high risk for engaging in risky sexual behaviors (CDC, 2012). Further, African Americans continue to be underrepresented in service delivery and are likely to experience multiple barriers when attempting to access mental health interventions (CDC, 2005). In fact, limited access to mental health resources has been found to be associated with increased risk for African American children and youth to develop internalizing and externalizing behaviors (Banerjee, Rowley, & Johnson, 2015; CDC, 2005). In addition, once African American youth engage in maladaptive behaviors, they are at an increased risk for disproportionate contact with the juvenile justice system, as well as confinement (Piquero, 2008). Dissemination of efficacious PT interventions with African American populations. A large body of literature has documented the many cultural strengths that African American families have embraced to cope with oppressive backgrounds such as slavery and segregation. However, there continues to be a lack of studies documenting the efficacy of PT interventions adapted for this population (Brody et al., 2004; Coard et al., 2007; Davey & Watson, 2007; Elmore & Gaylord-Harden, 2013). Unfortunately, the majority of existing PT efficacious interventions with low-income African American populations do not explicitly address the role of contextual stressors (e.g., systematic segregation, racial profiling, discrimination) on the quality of family interactions (Coard et al., 2007). Therefore, the existing literature documenting the impact of culturally adapted PT interventions for African American populations continues to be seriously underdeveloped. Among existing studies of PT interventions specifically adapted for African Americans, empirical data indicate high implementation feasibility, cultural acceptability, and initial efficacy 27 (e.g., Brody et al., 2006; Coard et al., 2007; Myers et al., 1992). For example, the Strong African American Families (SAAF; Brody et al., 2004) program is an intervention designed to discourage high-risk behaviors among African American youth and promote individual and family strengths. SAAF is based on family skills training as well as developmental considerations relevant to African American families (Brody et al., 2006). Cluster randomized prevention trials of the intervention have corroborated that improved parenting practices led to positive behavioral outcomes in African American youth (Brody et al., 2006). An additional example of a culturally informed PT intervention refers to the Black Parenting Strengths and Strategies (BPSS) program, which is a cultural adaptation of the efficacious intervention known as Parenting Strong Willed Child (PSWC) program (Forehand & Long, 2002). BPSS was adapted for low-income African American parents of young children. In addition to integrating the core components of the original PSWC intervention, the BPSS intervention incorporates sessions focused on culturally specific parenting practices in the context of the socio-political realities impacting African American families (Coard et al., 2004). Findings from a RCT indicate that the culturally adapted BPSS intervention was successful in improving parenting practices and child behavioral outcomes (Coard et al., 2007). Racial socialization. As PT interventions are increasingly adapted for African American populations, scholars have strongly suggested the need to integrate culturally relevant components for African American populations (Pearl et al., 2014). For example, a large body of literature suggests that racial socialization practices are at the core of child rearing experiences in African American families (Caughy et al., 2002). In essence, racial socialization refers to the process by which parents convey messages to their children about race, including teaching children coping skills in preparation for the discrimination they are likely to experience due to 28 their racial and ethno-cultural backgrounds (Hughes et al., 2006). With the exception of a few model interventions such as the ones previously presented, PT interventions have minimally addressed racial socialization issues when delivering parenting interventions to African American families. Addressing this gap in research is highly relevant, as the literature indicates that racial socialization parenting practices are associated with positive outcomes in African American children and youth (Caughy et al., 2002). For instance, Beach et al. (2016) found that changes in parenting behaviors, including an increase in racial socialization, partially mediated the effect of a PT intervention focused on youth behavioral outcomes and fully mediated its impact on youth self-concept. Given the saliency of a clear focus on racial socialization issues in interventions targeting African American populations, there is a need to continue to develop culturally adapted interventions according to this critical construct. Similarly, it is essential to continue to evaluate the impact of these adaptations (Coard et al., 2004; Elmore & Gaylord-Harden, 2012). Intimate Partner Violence Intimate partner violence (IPV) represents a severe and widespread public health problem in the US (Bair-Merritt et al., 2014; Black et al., 2011; Garcia-Moreno& Watts, 2011). IPV refers to physical violence, sexual violence, stalking, psychological aggression, economic abuse, and/or coercive acts committed by a current or former intimate partner (CDC, 2013). According to the most recent IPV survey conducted by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (Black et al., 2011), “nearly 3 in 10 women and 1 in 10 men in the United States have experienced rape, physical violence, and/or stalking by an intimate partner” (p. 33). CDC prevalence studies indicate that men are the most common perpetrators of various forms of IPV. Specifically, across all forms of violence, the majority of 29 bisexual and heterosexual women identify their perpetrators as males (Walters, Chen, & Brieding, 2013). IPV often results in serious physical and mental health consequences for victims, including higher rates of physical injuries, depression, post-traumatic stress, and detrimental long-term health consequences (Bonomi et al., 2007; Black et al., 2011; Decker et al., 2015; Houry, Kemball, Rhodes, & Kaslow, 2006; Hegarty et al., 2013; Russell, Springer, & Greenfield, 2010). Research findings focused on the impact of IPV victimization point to long-term negative consequences in children’s cognitive, social, emotional, and/or behavioral functioning (Rossman, 2001). Children who are exposed to IPV typically show elevated rates of psychological, emotional, and behavioral problems (Scott & Mederos, 2012). Although extensive evidence has corroborated the deleterious effects of IPV on women and children, there is a dearth of studies documenting how a focus on IPV informs the development and delivery of PT interventions. Addressing this issue is critical, as physical abuse is only one manifestation of IPV. For example, coercive control in the context of the IPV literature refers to strategies often employed by batterers that resemble other crimes, such as kidnapping and harassment. In order to assert their control, perpetrators use various means to isolate and dominate their victims, ranging from open psychological attacks to control of financial resources and freedom of movement (Stark, 2009). Abusers can therefore systematically undermine and interfere with mothers’ parenting practices, making effective parenting extremely difficult (Edleson & Williams, 2007). Although the issue of coercive control is frequently addressed in the IPV literature, PT intervention studies rarely report how coercive control issues are identified and addressed in the parenting interventions (Callaghan et al., 2015; Jouriles & McDonald, 2015). 30 Given its high prevalence and detrimental consequences, it is necessary to thoroughly inform PT programs of research according to IPV considerations. For example, PT interventionists should be aware that perpetrators of IPV are very likely to distort the concepts learned in parenting programs and use them to refine their own controlling tactics. Batterers may use the insights learned in parenting programs to criticize their partners’ parenting as opposed to examining their own (Bancroft & Silverman, 2002). Additionally, IPV survivors may have limited power to engage in positive parenting practices not condoned by their abuser and may be undermined when attempting to practice new skills. Therefore, it is of great importance to address these issues in PT programs with ethnic minority populations involved in the CWS due to the high risk of IPV and the likelihood of underreported victimization (Hien & Ruglass, 2009; Lipsky et al., 2012; Rizo & Macy, 2011; Waller et al., 2012). This investigation sought to address this significant gap in the literature by exploring the impact of IPV and coercive control on participants’ parenting practices. 31 CHAPTER 3: METHOD Research Design Overview of approach. This investigation had multiple research objectives. First, the study focused on exploring how the content of the PTC-R program, method of delivery, and adaptations by interventionists, facilitated or impeded the process of change reported by research participants. Further, the role of the co-parenting relationship was explored to understand its impact on the parents’ participation in the parenting program. In addition to co-parenting issues, dynamics of power and control and intimate partner violence, if reported, were explored. Finally, the study examined how the participants’ experiences in the parenting intervention impacted their relationships with others, as well as their own personal coping and life skills. To enrich the quality of the data, perspectives were gathered from parents exposed to the intervention, as well as interventionists certified in the model. This investigation consisted of an exploratory qualitative research design, guided by the tenets of Thematic Analysis (TA; Braun & Clarke, 2006) and core principles of Community Based Participatory Research (CBPR; Israel et al., 1998). Qualitative data were collected through in-depth, individual interviews with 14 parents who successfully completed the PTC-R intervention and were no longer involved in child welfare mandatory services. Interviews were also conducted with eight certified PTC-R group interventionists. Data were analyzed according to the recursive process of semantic analysis followed by latent thematic coding (Braun & Clarke, 2006; Clarke & Braun, 2013). Throughout this process, actions were taken to ensure the trustworthiness of the research findings. Justification for the use of qualitative methods. A qualitative research approach was selected for this study to thoroughly explore the experiences of low-income ethnic minority 32 parents’ after participation in a culturally adapted version of the PTC-R intervention. Qualitative research constitutes a process of inquiry well suited for this type of contextualized, in-depth exploration of social processes, and the meanings participants attribute to their experiences (Creswell, 2007; Merriam, 2009; Snape & Spencer, 2003). Qualitative research is particularly appropriate for studying phenomena and topics that are not well understood, such as the complexities of human experiences (Hill & Lambert, 2004; Ritchie, 2003; Snape & Spencer, 2003). This approach is useful for capturing in-depth descriptions of the diverse life experiences of underserved populations (Jarret, Roy, & Burton, 2002; Lapan, Quartaroli, & Riemer, 2011). A qualitative research design with individual, in-depth interviews was chosen because it privileges the voice of participants, minimizes power relationships, and explores issues within their context (Carter & Little, 2007; Merriam, 2009; Richie, 2003; Willig, 2001). This methodology is essential to adequately explore the impact of contextual challenges (e.g., discrimination, structural racism) that ethnic minority parents often experience. A qualitative research design also allowed for a critical examination of the strategies interventionists used to increase the cultural and contextual relevance of the intervention. Qualitative research can be experienced as a personal method of inquiry, which facilitates a trusting relationship between researchers and participants (Umaña-Taylor & Bacama, 2004). Therefore, data collection is characterized by a close interaction with a small sample of participants to facilitate proximity between the researcher and the different perspectives generated by participants (Merriam, 2009; Snape & Spencer, 2003; Willig, 2001). Qualitative methodology also creates opportunities for reflection and sharing of perspectives among participants (Stein & Mankowski, 2004). The use of in-depth interviews allows for a process of data collection that accounts for participants’ contexts, feelings, and personal experiences 33 (Merriam, 2009). Documenting the experiences of low-income ethnic minority participants who have been historically underrepresented in service delivery and research (Alegría et al., 2010) represents a unique opportunity to expand the current knowledge base related to the process of change associated with efficacious PT interventions. In qualitative methodology, the researcher is the primary instrument of analysis and facilitates the generation of findings from patterns of themes gathered from the data (Creswell, 2007; Merriam, 2009). Thus, qualitative research provides rich descriptions of participants’ experiences and a contextual representation of such experiences (Merriam, 2009). Finally, qualitative methodology allows researchers to validate participants’ experiences that are likely overlooked in society (Creswell, 2007). In this case, the parenting experiences of low-income ethnic minority parents who were also engaged in CWS were explored. Thematic analysis. Thematic analysis is a method for identifying and describing both implicit and explicit ideas and themes within the data (Guest, MacQueen, & Namey, 2012). These goals are achieved by providing a rich and contextualized analysis of individuals’ experiences and meanings associated with those experiences (Braun & Clarke, 2006). A constructionist thematic analysis approach was considered appropriate for this investigation based on the scholarship generated by the study conducted by Holtrop and colleagues (2014), in which a mechanism of change was delineated. Therefore, the constructionist approach was used to analyze data according to relevant themes previously identified in the literature, while also allowing researchers to identify alternative and emerging themes (Boyatzis, 1998; Braun & Clarke, 2006). Codes are then developed to represent the identified themes and capture the complexities of meaning within the textual data in a way that is transparent and credible (Guest et al., 2012). 34 Thematic analysis consists of six phases. First, the researcher becomes familiar with the data through data collection, field notes, and transcription procedures. Following this initial step, the researcher generates initial codes, searches for themes, and reviews the themes to generate a thematic map of the analysis. The final steps involve defining the overarching themes and producing a scholarly report of the analysis (Braun & Clarke, 2006). This investigation used an initial semantic approach followed by a latent approach to thematic analysis (Braun & Clarke, 2006). Initial themes were first identified within the explicit meaning of the data without further interpretation. Next, data were examined to identify underlying ideas, assumptions, and unique conceptualizations in order to highlight latent themes that may be informing the semantic content of the data (Braun & Clarke, 2006). Throughout this process, the primary focus of the data analytical process was to present the stories and experiences expressed by research participants as accurately and comprehensively as possible (Guest et al., 2012). Role of the researcher. In qualitative research, the researcher is the primary instrument in data collection and associated analytical processes (Merriam, 2009). Therefore, it was essential for me to address my role as the researcher and monitor my personal biases that were more likely to influence the research process (Braun & Clarke, 2012). Thus, I engaged in a series of reflexivity exercises throughout the study. Specifically, I wrote memos and journal entries documenting my assumptions regarding low-income families involved in CWS, the impact of discrimination and intimate partner violence in parenting practices, and the role of the interventionists. I recorded my reflections throughout the data collection and analytical procedures, focusing on how my values and life experiences may influence the implementation of the study, data analysis, and reporting of results. Through reflexive exercises, I recorded my 35 personal experiences and my internal reactions during the process of data collection and analysis, allowing me to monitor my own biases as I engaged in the process of research. Applying a CBPR Approach Community Based Participatory Research (CBPR). The CBPR paradigm emphasizes an active involvement of community members, agency representatives, and investigators in all aspects of the research process (Israel et al., 2003). Specifically, community research partners collaborate with researchers in all stages of the investigation, including the selection of the research design, recruitment procedures, implementation of the study, data analysis, and dissemination of findings (Fielden et al., 2007). Participatory approaches have been found to be effective in research with diverse populations because these approaches place an emphasis on collaborating with participants to identify unique contextual stressors that affect their lives. These stressors might include fear of being discriminated against by service providers, experiences of social isolation, or the stigma resulting from involvement in the child welfare system (Finno-Velasquez, 2013; Kumpfer et al., 2002; Pantin et al., 2003). This paradigm promotes a collaborative approach to developing research procedures that are culturally sensitive and appropriate for the target population. Additionally, CBPR has the potential to empower target populations as community leaders and resources are identified and research becomes a tool to enhance existing community strengths (Israel et al., 1998). Background of the study. This study was first conceptualized in summer 2015, after a series of conversations were held among the principal investigator and co-investigators, key personnel from Implementation Sciences International, Inc. (ISII), and the director of foster care and adoption at the Coalition for Hispanic Family Services. In essence, there was high interest to evaluate the implementation of the intervention because the original contract only included 36 funding support for training and implementation. The Coalition represents the largest community-based social services agency in Brooklyn, New York, committed to serving lowincome ethnic minority populations. ISII is the organization that was contracted to provide training and intervention delivery support for the implementation of the intervention. Within the city of New York, the Coalition is one of the five agencies selected as leading organizations of the Child Success NYC (CSNYC) pilot project that began in 2012. The CSNYC project is the New York City’s Administration for Children’s Services’ (ACS) newly integrated model for family based foster care. CSNYC integrates the delivery of evidence-based interventions aimed at improving the stability and wellbeing of children in foster care (Citizens’ Committee for Children of New York, 2013). The Coalition was selected to pilot test the implementation of three evidence-based practices for families in the state’s CWS, including the PTC-R intervention. ISII was offered a contract to provide training and supervision to all agencies participating in the CSNYC project and that were also implemented the PTC-R intervention (Chamberlain et al., 2016). Design. Initial conversations with community collaborators addressed the need to conduct a qualitative examination focused on the overall impact of the PTC-R intervention with low-income and ethnic minority parents, taking into consideration the contextual challenges to which these families are exposed. This research focus was highly appealing to the research collaborators at the Coalition as they would significantly benefit from having an in depth understanding of the experiences of participants exposed to PTC-R. ISII collaborators were also highly interested in this potential collaboration due to the limited qualitative literature focused on exploring mechanisms of change associated with the GenerationPMTO intervention, particularly among low-income ethnic minority populations. I was particularly interested in contributing to 37 these efforts based on my personal research interests, but was concerned about the feasibility of this study for a dissertation. Therefore, through negotiations with community collaborators and in consultation with ISII, it was agreed that I would engage in an exploratory qualitative study of the PTC-R intervention. After reaching common agreement regarding the focus and relevance of the proposed study, a series of meetings and conference calls were held to further clarify and refine the research aims and objectives. In those calls, we had regular conversations with research partners aimed at refining the research questions, interview guides, and recruitment and data collection procedures. Administration for Children’s Services (ACS). Upon approval of the original design by the dissertation doctoral committee and the Michigan State University Institutional Review Board (IRB), a research proposal was submitted to the ACS Office of Research and Analysis. The ACS Research Review Committee met and discussed all investigation materials (e.g., design of study, recruitment strategies, consent forms, interview protocols, etc.). After addressing initial questions and concerns, the ACS Research Review Committee approved the project. The guidance and continuous support of Mr. Howard Sklar, director of ACS’ research review committee, was critical throughout this process as there was a need to fully ensure that ACS’ goals were thoroughly met. Implementation. Once ACS approval was obtained, I scheduled an in-person meeting with the Coalition professionals selected to be my main contact persons: Ms. Andreina Silvera, trainer of trainers for the CSNYC program and Ms. Alexandria Muñoz, the director of foster care and adoption and CSNYC’s program supervisor at the Coalition. Ms. Silvera was instrumental in finalizing recruitment and logistical procedures. The implementation of this study relied heavily on the participation of these key community partners in the research process. Following CBPR 38 tenets, I became a co-learner alongside with parents and interventionists in the community as they reflected on their experiences associated with receiving and delivering the intervention (Israel et al., 1998; Wallerstein & Duran, 2006). Dissemination of findings. Study findings will be dissiminated to all community partners according to the format that they have identified will be most relevant to their goals (Israel et al., 2003). For instance, ACS would prefer a short written report of the findings, whereas the Coalition would prefer a presentation of findings to their Board of Directors. The results of this study will also be dissiminated to the developers of the intervention and to the larger scientific community through referred publications. Overview of Participants and Implementation Site Research participants were parents and primary caregivers living in New York City and who completed the PTC-R program within 3 years prior to their participation in this study. In addition, all participant families were discharged from child welfare services at the time of enrollment. The target site for this study was the Coalition for Hispanic Family Services (Coalition), a community-based comprehensive family service agency located in Brooklyn, New York. The Coalition is one of five agencies piloting CSNYC, a project consisting of three integrated evidence-based programs throughout the city of New York (Chamberlain et al., 2016). The Coalition is the largest nonprofit family services agency in New York City serving the North Brooklyn communities of Bushwick, Williamsburg, and East New York. The Coalition also serves the Queens communities of Ridgewood, Elmhurst, and Corona, serving both Kings County and Queens County. The Coalition offers an array of family focused services, including foster care and adoption, mental health services, afterschool and summer programs, and parenting support programs. This community agency serves approximately 7,000 low-income 39 ethnic minority families every year. Most services are available in English, Spanish, and other languages (Coalition for Hispanic Family Services, n.d.). At the time of recruitment, the Coalition had 8 approved PTC-R certified interventionists from diverse backgrounds and was in the process of certifying 10 additional caseworks (A. Silvera, personal communication, May 15, 2016). Kings County has an estimated resident population of 2,636,735 inhabitants. With regards to racial/ethnic background, 49.3% are Non-Hispanic White, 34.8% Black, 12.4% Asian, 1.1% other races, 2.4% multiracial, and 19.5% of Latinx/Hispanic origin (U.S. Census Bureau, 2015a). Queens County has an estimated resident population of 2,339,150 inhabitants, with a racial/ethnic background integrated by 48.7% Non-Hispanic White, 20.6% Black, 26.3% Asian, 1.5% other races, 2.8% multiracial, and 28% of Latinx/Hispanic origin (U.S. Census Bureau, 2015b). Although the median annual household income among all residents living in Kings County is $46,958 (U.S. Census Bureau, 2015a) and $57,210 for residents living in Queens County (U.S. Census Bureau, 2015b), the vast majority of families receiving services at the Coalition live below the poverty level (Coalition for Hispanic Family Services, n.d.). Overall, the Coalition primarily provides services to low-income African American/Black and Latinx children and families. The Coalition’s programs consist of comprehensive services to address the needs of underserved families exposed to contextual adversity (A. Muñoz, personal communication, February 25, 2016). Recruitment. Consistent with CBPR tenets, all recruitment activities were carried out by the principal investigator in close collaboration with the Coalition’s personnel involved in the coordination and implementation of the PTC-R intervention. Several potential barriers were identified in these conversations, including participants’ potential mistrust of formal health and 40 health care systems, CWS-related systems, and a Latinx researcher who is not a member of their communities. Thus, I engaged in a series of conversations with the director of foster care and adoption (also CSNYC program supervisor) and Ms. Andreina Silvera, who served as my primary person of contact. Ms. Silvera is an experienced interventionist and PTC-R trainer of trainers. These planning discussions were aimed at reviewing research procedures to increase the likelihood for participants’ sense of safety and comfort with all the phases of the study. Inclusion and exclusion criteria. To be included in the study, parents had to meet five inclusion criteria. First, they had to be a biological parent or primary caregiver, in a single or two-parent family. Second, parents must have completed the PTC-R program by the time of enrollment in the study. This inclusion criterion ensured that every participant in the study was exposed to all the core components of the intervention, methods of delivery, and additional characteristics of the PTC-R intervention. In accordance to CSNYC guidelines (A. Muñoz, personal communication, March 1, 2016), individuals were considered to have completed the PTC-R intervention if they attended at least 8 out of the 10 PTC-R sessions. Third, participants must have received the intervention from a certified PTC interventionist or during the certification phase of the interventionist’s training. The process of certification ensures that interventionists are thoroughly trained in the model and deliver the PTC-R program with fidelity. Fourth, all individuals in the study had to be 18 years of age or older. And finally, participants were included in the study if they were interested in participating in one in-depth individual interview regarding their experiences with the PTC-R program. Parents were excluded from the study if they did not meet the aforementioned inclusion requirements or if they: (a) had an untreated serious diagnosed mental health condition that impeded their ability to participate in the study, (b) had a serious substance abuse problem 41 without active engagement in treatment, or (c) had not been discharged from child welfare and foster care services. The Coalition leadership screened participants for the exclusion criteria before generating a list of potential research participants. With regards to participating interventionists, only certified and approved PTC-R interventionists were invited to participate in this study. The program supervisor confirmed their certification status before interventionists were invited to participate in the study. Procedures Recruitment of parents/primary caregivers. The agency’s director of foster care and adoption initially reviewed all case files and identified parents who had completed the program and were discharged from child welfare services. She assumed leadership for the initial review as she is responsible for reviewing all cases and oversees the implementation of the PTC-R program. Next, the agency’s PTC-R supervisor contacted potential participants’ previous caseworkers to obtain the parents’ contact information. Once she had a list of potential participants and their information, she either contacted these individuals by phone, Facebook, or sent letters that briefly explained the study according to a recruitment script provided by the principal investigator. During the initial contact with interested parents/caregivers, she clearly expressed that participation in the study was completely voluntary and would not impact their relationship with the Coalition. She explained to all potential participants that an external researcher would conduct individual interviews and that no personnel from the agency would have access to information linking participants to individual responses. If parents or caregivers expressed an interest in the study, they were invited to hear more from the researcher who formally consented participants before conducting the interview. Participants were informed that the researcher was traveling from another state and that meetings 42 had to be confirmed for the researcher to prepare her schedule. Once travel dates were confirmed, participants received calls and text messages to remind them of the meeting. Recruitment of interventionists. The director of foster care and adoption initially identified all certified PTC-R interventionists. Next, Ms. Silvera then had informal conversations with them about the objectives of the study and confidentiality procedures. I also had the opportunity to meet with interventionists during the first two data collection visits to discuss the goals of the study, the importance of their perspectives, confidentiality concerns, and any questions they had about the study. I invited all eligible PTC-R interventionists to participate in one individual interview. All interventionists were interested in participating in the study. To clarify, in order to be certified PTC interventionists, candidates initially engage in a five-day long training on the model. Following the initial training, candidates facilitate the PTCR intervention alongside a certified PTC interventionist to obtain informal and formal feedback from the program supervisor and trainer of trainers. In order to apply for certification with ISII, candidates must have co-led at least three PTC-R groups and one PTC-RH, with acceptable fidelity scores. ISII reviews all certification materials and determines if the candidate qualifies for certification. Participants. Fourteen parents/primary caregivers and eight interventionists participated in this investigation. During the recruitment phase, 36 parents met all eligibility criteria. Contact information for 32 parents/caregivers was obtained and they were all invited to the study via telephone calls, brief letters, or private Facebook messages. Fourteen of the initial 32 parents/caregivers who were contacted, participated in the research study. Nine of the remaining 18 parents/caregivers were unreachable after several attempts and the rest cancelled or did not attend their appointments. The corresponding descriptions are presented below. 43 Parents/primary caregivers. The majority of parents/primary caregivers who participated in this study self-identified as female (93%). Participants ranged in age from 23 to 47 years old. Most participants identified as Latinx/Hispanic (63%), and half of them identified Spanish as their dominant language, with only 14% identifying English as their dominant language. The remaining participants self-identified identified as African American/Black (21%) or multiracial (14%). Approximately two thirds of participants were unemployed at the time of the study and reported an annual income of less than $10,000. The rest of the parents reported an annual income between $10,000-$30,000. Most participants reported achieving a lower degree than high school and the majority reported being single at the time of the study. All of the parents who participated in this study were successfully reunified with their children at the time of this study. However, one participant reported sending her child back to her home country after reunification to avoid further involvement with ACS. Detailed participant demographic information is reported in Table 3.1. Table 3.1: Demographic characteristics of parents/primary caregivers Demographic Characteristic Gender Female Male Age 23-30 31-40 41-50 Race/Ethnicity & Language Hispanic/Latinx - Spanish language dominant Hispanic/Latinx - English language dominant African American/Black Multiracial Number of Children 1 2 3 4 44 n % 13 1 93% 7% 6 5 3 43% 36% 21% 7 2 3 2 50% 14% 21% 14% 4 1 2 3 29% 7% 14% 21% Table 3.1 (cont’d) 5 6 7 9 Education No schooling 7th grade 8th grade 9th grade 11th grade High School/GED Some college Relationship Status Single Partnered not living together Living together Separated Married Employment Status Unemployed Half time Full time Annual Income < $10,000 $10,000 - $20,000 $20,000 - $30,000 1 1 1 1 7% 7% 7% 7% 1 2 2 2 3 3 1 7% 14% 14% 14% 21% 21% 7% 9 1 2 1 1 64% 7% 14% 7% 7% 9 3 2 64% 21% 14% 8 4 2 57% 29% 14% Interventionists. Eight PTC-R interventionists participated in this study. All interventionists had experience delivering PTC-R groups since the beginning of the CSNYC pilot project in 2012. All interventionists were female, five identified as Latinx, two as Black/African American, and one as Caucasian. Data Collection Overview of procedure. Data collection was completed in three separate trips to NYC. At the conclusion of the recruitment process, the first data collection trip was exclusively 45 focused on parent/primary caregiver interviews. Interviews with interventionists were conducted in the second and third data collection trips. Interviews with parents/primary caregivers. In collaboration with the director of foster care and adoption and PTC trainer of trainers, we determined that a private space in the Coalition’s building was most suitable for conducting the interviews. After several cancellations/no-shows during my first data collection trip, the Coalition community partners and I determined the importance of giving participants the option of completing the interviews at alternative locations. Thus, participants were offered the option of completing the interview at their homes, a local community center, or a private room at the Coalition. Of the fourteen interviews conducted, only one parent chose to complete the interview at her home. Parents were also given the option to be interviewed in English or Spanish. Half of the interviews were conducted in Spanish. Finally, interviews were offered at a variety of times to accommodate participants’ schedules as best as possible. All interviews were conducted by the principal investigator, who has extensive experience in conducting qualitative interviews in research projects. Each interview began with rapport building and thanking parents for their participation in the study. Establishing rapport is a crucial factor for conducting successful in-depth interviews (Legard et al., 2003). Next, I described the study’s objectives and interview process. I carefully reviewed the consent document with participants, answered any questions they had, and obtained their signed consent. The informed consent documents are provided in Appendix C (English version) and Appendix D (Spanish version). Participants were also asked to complete a brief demographic questionnaire prior to the beginning of the interview (see Appendices I and J). Once the paperwork was completed, the interview began. Interviews ranged 46 from 37 minutes to 91 minutes, with an average of 64 minutes. All participants received a $30 gift card and a round trip bus card as compensation for their time and assistance. Interviews with interventionists. Initially, I proposed to conduct phone interviews with interventionists. However, during the pre-data collection visit at the Coalition, the agency collaborators and I concluded that conducting face-to-face interviews would be more conducive to building rapport and increase the likelihood of gathering more relevant data. All certified interventionists were invited to participate in the study and all participants accepted. The interview protocol with interventionists resembled the one followed with caregivers. The corresponding consent form is provided in Appendix E. Interviews ranged from 35 minutes to 113 minutes, with an average of 64 minutes. All interventionists received a $30 gift card for participation in the study. Interview guides. The original semi-structured interview guides used in this study were developed to address the main research questions, including Holtrop et al.’s (2014) process of change model (Legard, Keegan, & Ward, 2003; Willig, 2001). The original parent/primary caregiver interview guides are included in Appendix F (English version) and Appendix G (Spanish version). Similar procedures were followed to design the interview guide for interventionists. The complete interview guide is included in Appendix H. Modifications to the research questions. As the data collection process unfolded, it became clear that two sub-questions included in the original set of research questions were not worded appropriately. Specifically, participants could not provide insights to my inquiries on cultural adaptation. After reviewing the issue with my dissertation advisor and doctoral committee, we concluded that rather than the cultural adaptation topic being irrelevant, the inquiry approach was not appropriate. We concluded that the content area had to be explored 47 through alternative ways. For example, exploring the participants’ satisfaction with the adapted examples and role-plays constitutes an alternative approach to evaluate the quality of the cultural adaptations made to the PTC-R curriculum. Additionally, interventionists were able to provide more insight on the cultural adaptations they conducted. Therefore, I eliminated two original research questions as originally stated, but maintained the exploration of selected content areas through alternative questions, which had more relevance to participants. Prior to implementing these changes, I obtained approval from the doctoral committee. The two secondary questions pertaining to parents that were eliminated with committee approval were: (a) How did cultural adaptations implemented by interventionists facilitate or impede the parents’ process of change? and (b) If power and control issues or intimate partner violence were reported by participants and/or identified by interventionists, how did these experiences influence the participants’ experience in the intervention? Data management and preparation. I personally transported the raw data from the collection site to a research laboratory with restricted access at Michigan State University. All digital recordings were saved in a password-protected digital folder in a password-protected computer. Paper files were also kept in a secured and locked cabinet in the research laboratory. All IRB and ACS recommendations were carefully followed to ensure the safety of the data and confidentiality of participants. All audio recordings were digitally recorded and transcribed by transcribers who followed confidentiality procedures. The principal investigator read all transcripts while listening to the original audio recordings in order to ensure the quality of the transcriptions. Note taking and journaling. I engaged in multiple forms of note taking to capture additional data throughout the implementation of the study. Notes were recorded in a variety of 48 formats throughout the process of data collection and analysis to best suit my needs as a researcher. The different types of notes recorded are summarized in Table 3.2. Table 3.2: Note taking and journaling Type of Notes Field Notes Audit Trail Reflexive Journal Note Characteristics Written accounts about observed behaviors or events Contain minimal interpretation Used to keep track of methodological decisions Can be used to establish the dependability and conformability of the findings (Lincoln & Guba, 1985) Personal critical self-reflection and insights Used to monitor biases and role of the researcher (Merriam, 2009) Data Analysis Overview. Data were analyzed according to the thematic analysis approach. Thus, patterns within the data were identified according to a constructionist thematic analysis approach (Boyatzis, 1998; Guest et al, 2011). This approach was used to provide a detailed and nuanced account of the experiences of research participants (Braun & Clarke, 2006). Data analytical procedures followed a sequential process, involving two levels of analysis. Specifically, data were first analyzed at a semantic or explicit level (Boyatzis, 1998). Next, a latent level of analysis was utilized, in which underlying ideas, assumptions, and unique conceptualizations that may have informed the semantic content of the data were identified (Braun & Clarke, 2006). A summary of the six phases of thematic analysis used to analyze the data is reported in Table 3.3. Table 3.3: Phases of thematic analysis Phase 1 Becoming familiar with the data Phase 2 Generating initial codes Read transcripts while listening to the audio recording Note taking of observations and personal insights Systematically coded entire data set for content related to the research questions 49 Table 3.3 (cont’d) Phase 3 Searching for themes Phase 4 Reviewing themes Phase 5 Defining and naming themes Phase 6 Producing the report Collapsed codes that had similar content under a broader category/theme Examined how well themes captured the coded content Examined how well themes fit within the universe of themes Refined details of each theme Assigned descriptive names to each theme Selected salient and descriptive quotes to illustrate each theme Organized themes according to research questions and theoretical frameworks Final write-up Qualitative computer software. NVivo 10 software was used to conduct analytic procedures (QSR International, 2014). This software allows researchers to import raw data, code it, and collapse it according to the coding scheme. Trustworthiness Trustworthiness of the data refers to the importance of demonstrating that research findings are the result of implementing rigorous methodological procedures and that findings accurately describe the experiences of participants (Morrow, 2005). Four criteria of trustworthiness must be achieved in qualitative studies: (a) credibility, (b) dependability, (c) confirmability, and (d) transferability (Lincoln & Guba, 1985; Morrow, 2005). Credibility. Credibility refers to the extent to which findings are a clear and accurate representation of the experience of participants (Merriam, 2009). Thus, I used triangulation and member checking to reach this goal (Lincoln & Guba, 1985). Specifically, my dissertation advisor randomly reviewed 30% of the coded transcripts and provided feedback about specific coding issues. Discrepancies in the understanding of specific codes were discussed until agreement was reached. 50 As interviews progressed, I frequently re-stated answers to participants to confirm my accurate understanding of their answers. In addition, during the data collection process, I frequently met with agency collaborators to discuss emerging findings. Once data collection and preliminary data analysis were completed, I engaged in formal member checks. To conduct these, I contacted participants by phone, explained the process of member checking, and asked if they were interested in providing feedback regarding the findings. If participants agreed, I reviewed the main findings associated with their individual interview and asked them to evaluate the extent to which my identified themes accurately described their life and parenting experiences. I conducted member checking with one third of participants, chosen at random. Dependability and confirmability. Dependability and confirmability are interrelated concepts that refer to ensuring that the findings are the result of the implementation of adequate methodology (Lincoln & Guba, 1985; Merriam, 2009). To ensure dependability and confirmability, I documented the frequency of mention of themes that participants addressed when presented with open questions and that did not require specific probing (e.g., Please talk about the program components that were most relevant to you). I also kept an audit trail and research journal to document key methodological decisions taken throughout the research process (Morrow, 2005). I also worked closely with my dissertation advisor throughout the analytical process, informing him of my methodological decisions and providing him with copies of all transcripts and coding materials. Finally, I engaged in member checking with participants to ensure that my decisions had the expected outcome with regards to facilitating the gathering of accurate and clear data. Transferability. Transferability indicates the extent to which research findings are generalizable to alternative populations (Morrow, 2005). Due to the small sample design of 51 qualitative studies, claims of generalizability cannot be justified. However, current findings can be used to formulate operating hypotheses in similar contexts and populations. Thus, the major task to achieve transferability refers to providing data that allow researchers to decide the extent to which study findings are applicable in alternative contexts (Lincoln & Guba, 1985). To reach this goal, I provided detailed information about the design and implementation of the research study, research participants, and key adjustments made to the original research protocol. I also kept track of personal biases that could have influenced data collection and analysis (Merriam, 2009). 52 CHAPTER 4: RESULTS Parents3 and interventionists provided detailed narratives associated with the cultural and contextual relevance of the PTC-R intervention. In addition, participants described the perceived usefulness of the intervention’s core and supportive components, as well as teaching tools. Further, parents discussed the process through which their experiences in the intervention led to changes in their parenting practices, relationships with others, and coping skills. Finally, parents and interventionists provided specific recommendations for improving the relevance and impact of the PTC-R intervention. Figure 4.1 provides a graphic overview of main findings related to the cultural and contextual relevance of the intervention, core and supportive components, and intervention delivery method. Figure 4.2 presents a description of the participants’ process of change related to parenting skills, as well as suggestions for improving the intervention. Figure 4.1: Cultural and contextual relevance of the PTC-R intervention 3To increase clarity of presentation, the term parent is used to refer to both parents and primary caregivers. 53 Figure 4.2: Participants’ process of change and additional areas of improvement Cultural and Contextual Relevance of PTC-R: Participants’ Perspectives Overall, participants expressed clear consensus indicating the positive impact of the PTCR intervention. Parents discussed several themes relevant to their needs as low-income ethnic minority parents involved in CWS. Empowerment through parenting: “Nobody’s born knowing how to be a parent.” The majority of participants described the importance of learning new parenting strategies, particularly after having one or more children removed from their home. One mother (participant #104) expressed, “My experience in the program was incredibly helpful because, really, nobody’s born knowing how to be a parent. It was there that I learned how to treat my child, how to raise her, how to give her love, but also rigor.” A mother (participant #109) also reflected on how the group experience helped her become aware of the reasons that led to her children’s removal by ACS: The parenting group helped me focus on the problem that had occurred. I wanted to get my kids back. I didn’t want people to think I was a bad mother, but someone who made mistakes. So, [in the parenting group] I understood why they removed them. It really hurt to have the children removed, but the classes helped me. 54 Parents often expressed a sense of gratitude as they recognized some of the changes they made in their lives as a result of their participation in the PTC-R intervention. One parent (participant #111) affirmed, “If I wouldn’t have received this program, I honestly don’t know how I would be acting. This program has helped me learn about being a parent. I’ve changed a lot.” A mother (participant #114) expressed a similar sentiment, “I don’t know who designed the program, but I think it addresses all the needs that one might have as a parent. It helped me understand things about parenting. I still have my two blue folders that I use as reference.” Finding hope: “Not all is lost.” Although the PTC-R intervention provided participants with important tools to improve their parenting and interpersonal skills, it also offered parents a sense of hope and validation of their efforts. One parent (participant #103) disclosed: I always wanted to know, ‘okay, I am doing this one thing right’… When you get your kids removed, you try to beat yourself up like, ‘what did I do wrong?’ But I was able to feel confident in the parenting class because I felt like ‘wow at least I’ve been doing some of this.’ Parents also identified attending the parenting intervention as a useful resource to help them cope with the aftermath of their children’s removal by ACS, as one mother (participant #107) affirmed, “The work that they given us in the parenting class was very helpful. After going through that dramatic experience, coming to class was like a coping skills for me – it kept me focused.” A mother (participant #104) also described how her participation in the PTC-R intervention gave her the hope and guidance she needed to get her children back. She asserted, “It helped me be hopeful about getting my daughter back. At first, I didn’t know what was going on. But they teach you. It helped me get the confidence I needed to do what I had to do.” Fostering a sense of community with other parents: “It set off a light bulb [in me].” The majority of parents reflected about the positive impact resulting from being exposed to an 55 intervention with other parents facing similar situations. Most parents reported feeling supported by the group and affirmed that the program helped them navigate a very difficult period of their lives. One mother (participant #103) said, “I just appreciated talking to other parents…because everyone is going through different life stages of the parenting journey. And it’s so important to hear if someone has experienced something before you.” A parent (participant #110) further explained, “It was a nice experience to share experiences with others. The facilitator would give us the information in a way that we could learn from each other, with examples. It was good since we were all so stressed out.” A mother (participant #107) reflected on her experience listening to other parents: When you sit there and you listen to other people's experiences and what they went through and you look at your own situation, you tend to do things a little differently. It sets off a light bulb in you…You get this idea to just try different things. So basically, it was new to me. It was refreshing. Coping with separation and reintegration: “Reunification can be very tough.” Parents often discussed the challenges associated with reunification, after a long period of separation from their children, as one parent (participant #114) expressed, “I felt like I was not their mother anymore, like I didn’t have the right to tell them not to do something or if their behavior is wrong. It hurt my heart…” The majority of parents identified the reunification process as a key period of time that required them to practice emotional regulation and positive involvement with their children. One mother (participant #106) explained: She had just learned how to walk. She had just turned one when she was removed. And when I got her back, she had just turned five. It was different. I'm happy that I took the Parenting [class] because had I not took it, I don't think I would've been so patient. I think I would've been upset because I would've felt like these are my kids, they need to listen to me, they need to do what I say, when I say, how I say... Several participants reflected on the challenges associated with their children feeling emotionally attached to their foster parents, as one parent (participant #111) expressed: 56 At the beginning, it was hard because she was very used to the lady that took care of her. She would constantly tell me that she wanted to go back to the lady’s house. I felt really bad. But I would also say to myself, ‘It was our fault that they took her away.’ And then I learned I had to dedicate even more quality time to her so that she gets close to me again. Now we are so close. A mother (participant #104) reflected on her desire to support her child throughout the reunification process, as she affirmed, “Yes, I am still in communication with the foster mother because my daughter calls her mommy as well. I didn’t want my daughter to suffer so after she was returned to my care, I paid that foster mother to babysit her when I needed care for my child.” Personal growth beyond parenting: “They taught us how to speak.” A majority of parents reflected about the positive impact of the PTC-R intervention on their interactions with other adults and their personal coping skills, particularly as they worked toward family reunification. One mother (participant #108) affirmed, “I learned how to treat the case workers. I understood they were there to protect the children, not to hurt them.” A parent (participant #113) elaborated on this issue, “I learned to speak more properly, especially when it comes to the children or when there’s people – not speaking [badly] in front of the children.” Parents also discussed the importance of learning new interpersonal skills, as one mother (participant #105) affirmed, “They teach you. Like I always say, it’s like having a job – every job there is in this world, you’re dealing with people. So, you’re dealing with nasty people, kind sweet hearted people, doesn’t matter – people are still going to be there for you to deal.” These skills were particularly important for parents as they interacted with the court system. One parent (participant #102) explained: They would teach us how to speak. And then they would tell us the consequence if you did speak like that [with anger]. They were teaching how to speak to a judge or a lawyer. The judge is going to look at you up and down… And they teach you how to speak, and then they’re teaching you the consequences of how it would be, if you spoke like this. 57 Cultural and Contextual Relevance of PTC-R: Interventionists’ Perspectives Adaptations aimed at increasing cultural and contextual relevance. Interventionists reported clear consensus about the need to adapt the intervention in order to increase its cultural and contextual relevance. Interventionists also agreed that without such adaptations, it would have been extremely difficult to achieve successful engagement and retention of participants in the parenting program. Therefore, they engaged in a series of cultural adaptations to ensure that the intervention was culturally and contextually relevant for the target population. Engagement sessions. Interventionists reported that parents commonly experienced anger and disappointment when they first attended the parenting intervention. These experiences represented a considerable engagement challenge for interventionists as they attempted to present the intervention within a framework of hope for successful reunification. In response to this challenge, the Coalition leadership team created a two-session curriculum to facilitate engagement within this context. In these sessions, parents were encouraged to process the removal of their children and were validated on their struggles. One interventionist (participant #208) reflected on the goals of these initial sessions, “The mission is to set them up to be receptive to the PTC model, especially when dealing with mandated participants…once they understand who we are and what we are here to do, they are more focused. To me, if we skip that, we are not getting through session one at all.” An interventionist (participant #207) further explained the content of the two engagement sessions: Prior to starting PTC-R, we do two weeks of what we call engagement. And in that, we do from soup to nuts - how does a family become known to ACS all the way to either reunification or adoption. We talk about who the players are – who is ACS, who is the Coalition, who are the lawyers, and what are their roles. We talk about the importance of visitation. We talk about court. We talk about allegations. We talk about neglect and abuse. We talk about the idea of compliance to mandated services. And in that, we say ‘you are here for one mandated service, which is parenting.’ That’s key. Without that, they don’t understand why they have to take parenting. 58 Coalition leaders were particularly careful at matching engagement sessions according to the structure of regular PTC-R sessions, as one interventionist (participant #205) reported, “We run the [engagement sessions] like a PTC session. We have home practice assignments. We talk about the difference between ACS and Coalition, the foster care agencies. We talk about the service plans. We talk about their goals…” Bringing down barriers: Simplifying intervention materials. Interventionists uniformly agreed on the need to simplify materials that were originally too complex for the target population, which increased the risk of alienating parents. Thus, interventionists focused on simplifying materials while ensuring that the new materials adhered to the core components and principles of the intervention. All group facilitators reported that the revised materials were critical to ensure cultural and contextual relevance. One interventionist’s reflection (participant #202) illustrates feedback shared by other group leaders: Every group is different. So, in every group you have to look at who you’re working with and then you have to tailor it to that group because [in] some groups you can use some of the words in the book and other times, you have to use words that are really simple, so that they can get it... But you have to tailor it to the group. Most interventionists discussed in detail the challenges they experienced when they first introduced parents to specific parenting techniques (e.g., time-out sequence, token systems). They often reported having to tailor intervention materials to make sure they were culturally and contextually appropriate for parents. When discussing the impact of encouragement strategies for children, an interventionist (participant #208) shared the challenges she encountered when she first introduced the token system, as well as the modifications they conducted to address this barrier: The token system is a little tricky. We had to simplify it. For instance, you have to measure your audience and population. Sometimes the words that come with it are a little 59 bit too sophisticated and there could be too many steps. So one of the things we did was eliminate the actual word “steps.” We try to explain it in a simpler way or even gathering examples for them to understand what a token system is. Interventionists also expressed concerns about the cultural fit of the token systems with the population they serve, as one interventionist (participant #207) explained, “It’s really hard to deliver [the token systems] maintaining fidelity but also without shutting down parents. I think the concept is beautiful – it’s about focusing on positive behaviors. I just don't know about the tool itself…This idea of the tokens. It’s just really hard for our families.” An additional parenting practice that required careful adaptation and modeling by interventionists referred to the time-out sequence, which is included in the PTC-R limit setting skills. One interventionist (participant #204) reflected on her experience: Most [parents] have never been in time-out or experienced time-out. So, then there’s five ways in which we have to introduce this to the parents. It could be overwhelming because it has so many steps. And most of our parents don’t read. So, it becomes a little challenging. So, we have to tailor [it]. Sometimes you even have to stand and tell them what to say next because sometimes they’re too nervous. Sometimes they can’t read the words. Increasing contextual relevance. The majority of interventionists reported modifying many of the examples and role-plays in the PTC-R curriculum to increase their contextual relevance. Interventionists were uniform in their consensus with regard to the importance of carefully matching the parenting skills according to the very challenging contextual realities of the population they served. One interventionist (participant #207) explained: We have a population that has a multitude of contextual factors that they’re dealing with. And we try really hard to incorporate that into the lessons. We discuss hygiene. We discuss money management. We discuss identifying resources that are helpful to them. We discuss taking medication as prescribed. We really take the core components and stretch them as much as we can to make it applicable for the population that we’re working with. I mean our folks really need a lot, a lot of help. 60 The participants’ interactions with their children throughout the intervention delivery time frame were limited to supervised visitations, which considerably reduced their opportunities to practice the new parenting skills. Thus, the majority of interventionists reported having to frequently modify ice-breakers and role-plays to increase their relevance and applicability, as one interventionist (participant #205) affirmed, “For example, one ice breaker said, ‘how many times have you moved this year?’ Many of my families are homeless, and they’re struggling to find stability. I don’t want to trigger them by asking that. So…you have to make this curriculum match their reality and be very mindful of that.” An interventionist (participant #204) further elaborated on this issue, “So, [we tailored] the role-plays, because they’re very home-based or school-based or neighborhood-based. We make it relatable. It's a constant [issue to think about] when you’re role-playing to set up scenarios they can relate to.” An interventionist (participant #208) also reflected on the need to carefully tailor roleplays to ensure the fit with the participants’ daily experiences: We’ll use role-plays with the case planner or their significant other. We use a lot of real life examples to connect the material to their lives, as well. We always say, ‘You know you could try this with an adult in your house.’ Or we’ll use a telephone conversation. ‘When someone hangs up on you, how do you feel?’ So, we do make it very relatable to other aspects in their life. Relevance and Perceived Impact of GenerationPMTO Core Components Research participants provided detailed descriptions of the perceived relevance of the PTC-R core parenting components. Specifically, parents and interventionists identified limit setting as the most relevant and useful core component of the intervention. Parents also identified skills encouragement and positive involvement as highly relevant to their parenting efforts. Although monitoring and supervision was not a component included in the original PTCR curriculum, Coalition leaders addressed this content throughout the parenting program. Parents 61 experienced this component to be useful for their parenting practices, particularly because the majority of parents were involved in CWS due to neglect allegations (A.Muñoz, personal communication, June 2017). Therefore, interventionists reported often weaving in principles of monitoring throughout the PTC-R intervention. Finally, problem solving was rarely identified as a relevant component by participating parents. Limit setting: Parents’ perspectives. Parents identified learning new ways to discipline their children as the most relevant component of the intervention. According to the GenerationPMTO model, mild consequences are given to children and youth for misbehavior. If an initial consequence is not effective (e.g., time out), a mild back-up strategy is used (e.g., privilege removal). One mother (participant #107) reflected on the use of limit setting practices by considering the age of her children: And I realized when you put the child on time out it's according to their age. Like for my six year old, he goes on time-out for 6 minutes. For my three year old, he goes on timeout for 3 minutes. For the older children, I take things away or any kind of privileges are revoked. Although time-out was effective for some, it was not the limit setting strategy of choice for most parents. Rather, parents identified privilege removal as their preferred limit-setting strategy. One mother (participant #105) discussed the challenges she experienced when attempting to use time-outs. However, it appears that this mother may not have fully assimilated the key principles of the technique, as according to the intervention, time out should not last more than 10 minutes. This participant described her experience, “Time outs do not work for my son…not a five-minute [time-out], twenty minutes, an hour, two hours... So, I stopped time outs now. I take away his toys [now].” Some parents’ challenges associated with implementing time-out referred to the technique itself, whereas others grappled with its cultural and contextual relevance. A mother of 62 four children (participant #106) provided an insightful feedback about the importance of having enough support to effectively implement time-outs: Time out does not work for [my son] at all. When I actually got my kids, we [were] like ‘that stuff didn't work for our kids, that only works for White people, not for us’. I mean, maybe it would work…if it was more than one parent in the house and you had somebody supervising the time out…then it would work. Most parents identified privilege removal as a particularly effective limit setting strategy. This technique consists of temporarily prohibiting children from engaging in pleasurable activities that are not essential to their development (e.g., not playing with their favorite toy for 30 minutes). A parent (participant #111) explained, “If she misbehaves, then, when she asks to watch a video on my phone, I say, ‘Today you cannot use the phone because you did this thing wrong.’ And she says ‘Ok’ because she understands. I take away something she really likes.” A mother (participant #109) reflected on her desire to implement non-punitive discipline practices, emphasizing the usefulness of privilege removal: Since I took the classes, I understood that you don’t discipline a child with belts or whatever you have on hand like we were…from the moment they really like something, you can take that away [if they misbehave]. For me that was the most important thing, what I liked the most about the classes. Limit setting: Interventionists’ perspectives. The majority of interventionists confirmed parents’ reports identifying limit setting as the most relevant component for parents. Interventionists also reported participants’ struggles associated with learning the time-out technique, as well as parents’ preference for the privilege removal strategy. Further, interventionists reflected about their efforts to maintain fidelity to the intervention while presenting materials in culturally and contextually relevant ways. An interventionist (participant #201) described some of the difficulties she encountered when teaching parents how to implement the time-out procedure: 63 The tricky part is trying to keep it as close to the curriculum as possible when in reality some of these parents just can’t grasp the steps of a time-out. You have to really simplify it for it to stick... There’s a lot of steps, there’s a lot of rules about the space that you put a kid in time-out in, there’s a lot of rules about when you do and do not disengage, there’s so many steps to it…it can be overwhelming. Interventionists’ accounts resembled those by parents related to the use of privilege removal as the participants’ preferred technique for disciplining their children. One interventionist (participant #204) reflected on this issue, “What they [parents] do practice more is the privilege removal, which is taking something away for 30 minutes. That, you see more often. I think it’s a lot easier, especially if you have multiple children.” An interventionist (participant #207) further elaborated on this perspective: They do well with privilege removal. That, they get. You do this, you lose this. They can conceptualize that. Time out, it’s a little trickier. I think they see the value in it. We take a lot of time to talk about time out as a means to regulate your emotions as a parent. And so that it as much for you as it is for the kid, right? And I think once we do that, then they’re like, ‘oh, I’m down with that. I could do that.’ Skills encouragement: Parents’ perspectives. The second preferred core component identified by the majority of parents referred to skills encouragement, which refers to helping children master a variety of pro-social and self-sufficient behaviors (e.g., cleaning their room). Most parents discussed the usefulness of utilizing a variety of small incentives to reward children for positive behaviors. One mother’s (participant #103) account resembles insights shared by other parents, “I liked how the rewards wasn’t so much pressure on the parent. So, to see rewards in different kinds of light. For people to understand a reward can be a hug, a reward can be a kiss, a reward can be a video game.” Parents also discussed the relevance of using various social reinforcers to promote positive behaviors. One mother (participant #109) expressed: Incentives are so important because [children] feel encouraged. So, an incentive can be a hug, and that can be something big for them in that moment. You don’t have to give them something big. Even if it is just a hug or a smile, and [children] feel in that moment ‘Oh, I didn’t get anything’ but later, maybe the next day, they will think, ‘my mom gave me a 64 nice hug and we shared that moment’ …and they’ll come back and they’ll tell you, ‘We really had a great moment, we had such a good time.’ Parents frequently used a variety of incentives with their children to promote desired behaviors. They also experienced a high degree of satisfaction when their parenting efforts were effective. One parent (participant #111) described that experience: When she does something well, I congratulate her and tell her I will give her something [a small incentive]. So, later, I say ‘This is the prize you won for doing what you did before’ and she gets really happy and smiles and hugs me and I say to myself ‘wow, I am doing things right!’ Token system. According to the GenerationPMTO model, a variety of social and instrumental reinforcers can be used to promote pro-social behaviors (e.g., scoobies, stickers). However, the main incentive system taught in the PTC-R intervention is the token system. In essence, the token system refers to a system consisting of small reinforcers (i.e., tokens) that are used to encourage a variety of new skills and pro-social behaviors. The target behaviors can be multiple in nature and tokens must be carefully tracked to provide incentives. Although the concept of promoting skills through encouragement was clear to parents, none of the caregivers in this study were able to identify or recall the token system. Skills encouragement: Interventionists’ perspectives. Interventionists confirmed participants’ reports related to the caregivers’ overall satisfaction with the concept of skills encouragement and the use of incentives to promote pro-social behaviors. Thus, the notion of encouragement without being restricted to an elaborate system such as the token system was well received by parents. One interventionist (participant #203) reflected, “In some cases, I’ve seen parents identify strengths during the visit, like ‘oh, you grabbed the book, good job!’ An interventionist (participant #205) further expanded on this idea: I try to be very specific when teaching encouragement to parents…I talk about just how good it feels to hear the positives and how you’re going to do to repeat that behavior…I 65 think parents do a nice job encouraging the little ones, ‘Good job!’ or ‘Yes, you can!’ All that stuff. Token system. Interventionists described the token system as challenging to assimilate and incorporate into parents’ daily childrearing practices. For example, one interventionist (participant #207) described her concerns about the token system: I think for our population who struggles with academics and school and goals, that session can be so formal and so intense because it’s an actual practice. And to try to teach the parents how to practice that, it can really become very overwhelming for them. We’ve done a lot of work with not writing it out in steps. We’ve done a lot of work with simplifying it. Just breaking it into two parts, and not the ten parts. We provide them tokens. We provide them the bracelets. We provide them the stickers. We’ve tried to do a lot of stuff to really just make it about focusing on a positive behavior versus this is the session on the token system. An interventionist (participant #205) further discussed these challenges: The title [of the session] is “Teaching New Behaviors.” But the meat of that session is the token system. And even if you don’t want to, you kind of have to spend a good amount of time on the token system, which can take away from you really utilizing the time to say, how do you support your child in tying his shoes? That’s a new behavior. Or using his fork… The token system is just too much. Positive involvement: Parents’ perspectives. This core component refers to promoting warm and nurturing relationships between parents and their children. Parents often discussed how exposure to the intervention helped them find new ways for spending quality time with their children, despite the contextual challenges they were facing. For example, a mother (participant #103) described her creative use of common errands and appointments as opportunities to spend quality time with her children: I was always aware of the importance of that. It just was always like a struggle with time… But [now] for example, say a child has to go to the doctor. I would be like, ‘wow, an opportunity for us to do something else maybe and spend time.’ This is not just a doctors’ appointment. We could do this and that during the appointment waiting area. Sometimes you’re left there so long, we could utilize every moment to making it [about] spending time. A parent (participant #105) described her plans to spend quality time with her children: 66 I have to plan ahead of time for my kids. We are almost near the summer so I started planning the whole summer out. I’ve got different activities with them. Like I want to go to the zoo in a part that I know in Manhattan that’s really nice. It’s got picnic tables. I would like to take them there and have a little picnic. Parents also reflected about the challenges associated with this component after children were away due to temporary foster care placement, particularly because there is a need to rebuild the relationship through warm and positive affection. The words from one mother (participant #112) illustrate a common experience reported by other parents: I spend quality time, a lot of quality time playing together…Reading, trying to read even though we don't [actually read]. And I always tell him I love you. He never used to tell me, he never used to tell me he loved me. He just started saying it a lot more, ‘I love you mommy.’ Positive involvement: Interventionists’ perspectives. Interventionists reported witnessing how parents shifted from having a perspective focused on their children’s negative behaviors to identifying their children’s strengths. An interventionist (participant #208) reflected on this issue: Once we get them to shine the light on the [positive] behavior, it’s awesome. They know how to do it. I always ask ‘What happened last week? What did your child do good? What did you catch them doing well? What do we shine the light on?’ I use the language on them a lot to the point that they start mimicking the language. However, several interventionists reported that parents often struggled to identify their own personal strengths, impacting their ability to have nurturing and warm relationships with their children. One interventionist (participant #207) illustrated this issue: Our families do well with this idea of praise, with this idea of identifying strengths. It’s very, very easy for them to talk happily and proudly of their children and how amazing their children are. That’s not anything that they struggle with. They struggle tremendously with trying to do that for themselves. So that’s where we have to focus a little more. And we spend a lot of time focusing on them. Because if they can’t do it for themselves, then it gets really hard for them to see it in the kids. So we spend a lot of time actually celebrating anything that they do throughout the ten weeks, so that they can just hear it and learn the language and how to utilize it. 67 Monitoring and supervision: Parents’ perspectives. Parents expressed satisfaction with this intervention component, particularly after having experienced the removal of their children by ACS. A mother (participant #106) affirmed: I really am really careful about who they hang out with. I don't let them hang out with people outside the school. My son only has one friend in my building… But, I had to meet his parents before I even let him in my house. I had to make sure it was OK. I had to poke my head and see where, how they're living... It's hard trusting people to be around your kids, especially with what I went through with my kids. Parents also discussed how they adapted these skills according to specific examples of their daily lives, such as riding the train or being at a crowded shopping mall with their children, as one mother (participant #102) reported: [The interventionist] talked about it in the class. Don’t go with strangers. Always have a copy of your address with the child, God forbid, anything happens. [So, I tell my child], ‘You sit down next to me so you don’t get lost. Look at the stops. Look at the train stops. Look at the policeman, they’re your friends, they’re not your enemies. God forbid you get lost. Look at the ladies over there. Look at the cameras.’ I do that all the time with her. Monitoring and supervision: Interventionists’ perspectives. This component was not originally included in the PTC-R curriculum as children were removed from their parents at the time they were exposed to the intervention. However, the Coalition leaders decided to weave in monitoring and supervision concepts throughout the intervention. One interventionist (participant #205) described the importance of addressing this parenting skill throughout the intervention, “We have to bring monitoring up whenever there is a chance to talk about it. Whenever a parent guides me to it… It can come up at engagement. It can come up even in active communication.” Similarly, an interventionist (participant #208) elaborated on the importance of addressing this parenting skill in the PTC-R intervention even if children were not residing with their parents at the time of intervention delivery: 68 The children are not physically with them [parents], so how can they really monitor them? But, we also do get creative with it. You can still monitor the problems of the child. You’re allowed to go to medical appointments, you could ask about school. So, we do encourage them to say fully engaged. Just because your children aren’t physically with you, that doesn’t mean you cannot parent and monitor. Problem solving: Parents’ perspectives. Only two parents clearly identified this core component as useful to their parenting practices, even after caregivers were asked about this specific component in the interviews. In essence, problem solving refers to helping parents solve mild problems by generating alternatives to solve a problem through a brainstorming process, negotiating various potential solutions, and reaching consensus among family members to implement a final solution. One parent (participant #106) reported, “With my daughter problem solving is helpful. I can negotiate with her. She’s very reasonable.” A mother (participant #104) further described her use of the skills in negotiating activities with her child, “It helped me to learn how to negotiate with my daughter. I think about her age. Maybe she wants it, but perhaps I can’t do it in that moment. So, then I negotiate about the time and place.” Problem solving: Interventionists’ perspectives. The problem solving component was incorporated in the last sessions of the PTC-R curriculum, including the final session that preceded the graduation ceremony. Interventionists shared their concern about the timing of the delivery of this component. In addition to suggesting the need to address this component in a single parenting session, several interventionists reflected about the need to devote more time to addressing these parenting skills throughout the intervention, as one interventionist (participant #205) expressed: I think it’s too short. I would love to have a second session on it. Especially, because they are coming with the foundation of active communication, emotional regulation. You know encouraging, balancing, and limit setting…So, yeah, I think problem solving should probably be two sessions. This is a session that has a potential of having a lot of role plays. Oh, and then conflict resolution….We kind of tie [problem solving] in with conflict resolution, but I wish it was a little longer. 69 Relevance and Perceived Impact of GenerationPMTO Supportive Components The GenerationPMTO intervention has key supportive components aimed at enhancing the delivery of the five core intervention components and improving outcomes (Forgatch & Domenech Rodriguez, 2016). Participants in the study identified three key supportive components highly relevant: (a) emotional regulation, (b) active communication, and (c) giving good directions. In addition to directly benefiting their childrearing practices, parents perceived emotional regulation and active communication as highly beneficial for improving the quality of their interpersonal relationships with adults in various settings. Emotional regulation: Parents’ perspectives. Parents expressed uniform consensus about the high relevance of this component for their childrearing practices, personal coping strategies, and their interpersonal skills. According to the model, this component is aimed at teaching parents skills to help them identify and regulate their emotions in the interactions with their children. Parents provided multiple examples of these skills being particularly helpful to manage distressing emotions. For instance, one mother (participant #102) explained the personal strategies she learned to de-escalate conflictual interactions with her child: Sometimes I like to draw, listen to music, sing a song, be active… [I] take the hate away from me. Don’t bring it up with your child, so then your child can see you model. I don’t want my daughter hating nobody. Parents are the role models of the kids the way they act, they way they are, the way they feel. ‘If Mommy cries, I’m going to cry. Mommy’s angry, I’m angry.’ Interestingly, some parents framed the time-out concept as a self-regulatory strategy, as one mother (participant #103) stated: But at the end of the day I appreciate time out, even for myself. Because if I’m heated about something, I need a time out. Let me get it. Sometimes my kids wouldn’t let me get it and I’ll be like ‘Oh my god, I’m tryin’ to go that way. Let me get my moment of air that I need. I just need a moment to breath.’ 70 In addition to the relevance of emotional regulation skills for childrearing practices, the majority of parents reported using these skills to cope with daily stressors. In these situations, parents reported engaging in breathing and relaxation techniques, particularly in their interactions with other adults. A mother (participant # 107) illustrated a reflection frequently shared by other participants with regard to managing stress in various social interactions: The way that we talk to our children, we [also] talk like that to other adults. Like we get stubborn, we get nasty, we have our attitudes. And it's like we tend to dump all our crap on other adults for no reason… No matter who it is, you still have to conduct yourself in a professional manner, regardless of whether that person comes with an attitude or is having a bad day. You have to keep in mind that that is their problem, not yours. Let them, that's their problem, not yours, you know? A mother (participant #109) shared similar reflections: I also learned that when you are angry, you do something: count to ten, breathe. Because not everyone is perfect and there is always that moment when you get too angry. But, why take that out on the kids? Honestly, my attitude before [the parenting classes] was to be more aggressive with people, but listening to everything that was said in group…it was something that helped me. I learned how to treat an older person, how to contain myself when I get angry, how to help the children do that. The classes really did help me. Emotional regulation: Interventionists’ perspectives. Interventionists’ feedback on emotional regulation resembled parents’ accounts regarding the relevance of these skills. One interventionist (participant #202) affirmed: I think the sessions that stand out the most are the emotion regulation and observing. I know that a lot of the parents here have a hard time regulating their emotions, especially when they’re told something they don’t want to hear, like they’re not having a visit or something negative happened in court. They have a hard time just taking the time to regulate. So, I think that’s the biggest one for them - just being able to regulate day to day with people around them, with case planners, with court, with friends, with everybody. When discussing the significance of the emotional regulation component, interventionists often reflected on the contextual challenges that affect the families they served. Specifically, families served by the Coalition generally report economic and literacy challenges, substance abuse problems, and cumulative trauma (A. Muñoz, personal communication, June 2017). 71 Parents also often reported feeling confused and angry about their involvement with ACS, yet they struggled to identify and express their emotions. Thus, interventionists frequently used strategies aimed at managing emotional regulation, such as visual aids and role-plays. One interventionist (participant #204) reflected on these issues, “I think they register with [the emotional regulation sessions] because it’s a lot of pictures. So, it’s a lot of visual learning. They get really excited about emotions and looking at the pictures and putting stories to it. And the conversations are very rich and very meaningful.” An interventionist (participant #205) further elaborated about the active teaching elements that increased the sessions’ relevance for parents: Emotional regulation. These sessions include a lot of role-plays and a lot of our parents are visual learners. So they really retain the information from such active teaching. And then shortly after that, active communication follows. Which is key to parenting and dealing with their everyday lives. I’m hoping that they really stick to it. I’ve seen it have a bigger impact on them. Whether they speak on it or not, as a facilitator I see it, they get it. Active communication: Parents’ perspectives. This supportive component is introduced immediately after the emotional regulation sessions to help parents enhance the quality of communication with their children, which is particularly critical throughout the reunification process. A mother (participant #106) illustrated the impact of being exposed to this component: I feel with my daughter it was very helpful because that's how I kind of got her to listen to me more. I learned that instead of raising my voice and screaming at her, we could just sit down and talk. And with her that works a lot…She really communicates with me now. But my son has trouble communicating and expressing his feelings, and we learned in Parenting about this whole page of little faces, like an angry face, a happy face, a sad face, and all that stuff …They worked when I was trying to help him identify his feelings and express the way he was feeling instead of doing whatever. Beyond the direct benefit of improving the quality of communication with their children, parents frequently reflected about the usefulness of this component as it refers to relationships with other adults. One mother (participant # 114) reflected on this issue, “It was good that they 72 taught us how to listen. We learned to wait until the person is done speaking before reacting. Not like [before] - a person would be speaking and you would start talking before really listening. I try to practice all the time now, it’s part of my routine.” Active communication: Interventionists’ perspectives. Interventionists’ reports confirmed the high relevance of this core component for parents. In addition to the benefits associated with the relationship with their children and immediate social networks, interventionists also reflected on the benefits of these skills as parents interacted with case planners and other Coalition staff. One interventionist (participant #204) shared, “When active communication comes in, [parents] are putting together how your emotions can affect how you communicate. So, I think those sessions are important, and I feel those are what register the most with the parents.” An interventionist (participant #207) expanded on these ideas: [Parents’] ability to communicate effectively [is impacted by] the idea that you have to have a purpose and a goal and attention to whatever conversation or interaction you’re having with another person. And that you have ownership and responsibility and seeing that through. So part of that, is communicating effectively - staying calm, being goal driven, saying what you mean, meaning what you say. It really, really helps parents. Good directions: Parents’ perspectives. This supportive component was presented at the beginning of the PTC-R intervention and had the main goal of helping parents give children effective directions as a way to promote their cooperation and compliance. A majority of parents reflected on the positive impact of these skills. For instance, one parent (participant #105) affirmed, “They actually taught us a lot of good things: how to speak to children, which is good…how to go about the situation - you give them a small directive and you follow up the directive, [then] congratulate them, rewarding them with something small.” A mother (participant #104) described her experience after exposure to these skills: In the directions, I learned how to speak to [my daughter] and how to be specific, place and time. I remember to say her name and say what she’s doing in that moment and then 73 give the direction. Yes, that all helped me. So that I can talk to her in a clear and specific way, so that she can understand. Good directions: Interventionists’ perspectives. Interventionists reflected on the relevance of this supportive component for parents, as one interventionist (participant #206) stated, “People like the sandwich metaphor. [They] like how to give a direction.” Several interventionists agreed on the positive impact of this component on parents’ attitudes toward the material presented. One interventionist (participant #207) enthusiastically shared her observations: Good directions is great. It’s great! That’s when you start seeing little light bulbs. That’s when you see some level of ownership in regards to, ‘Damn, I don’t communicate well.’ That’s where we’re able to set an expectation of them. And they’re really trying. Some of them will say it out loud, like, ‘I’m trying to cooperate right now.’ And so, we’ve seen some of the hardest families really practice it and correct the staff when we don’t do it. And say, ‘That wasn’t a clear direction, you know?’ So, yeah, they really like that. Intervention Delivery Methods GenerationPMTO is delivered by utilizing specific intervention delivery methods, such as the practice of parenting skills though role-plays. Participants identified role-plays as having the most relevance to them. Participants also reflected on the usefulness of home practice assignments. Role-plays: Parents’ perspectives. Some parents reported initially feeling hesitant or uncomfortable about engaging in role-plays. However, the majority of parents reported that roleplays were useful to help them master new parenting skills. One parent (participant #111) explained: Well, at the time, I was embarrassed to participate. But if I really look at it, the whole thing about practicing being a child can be useful. I remember one time I was acting with someone and the other adult was the child and they talked back to me and I immediate thought about my daughter and how I [normally] respond. But instead, I lowered my tone and talked to the “child.” Now, I think about that when my daughter talks back to me. I try to talk to her in a good tone and everything. 74 Parents frequently reported their excitement about participating in role-plays. One mother (participant #101) said, “I truly, truly loved the role plays.” In addition to the enjoyable experience for parents, participants referred to the role-plays as particularly useful as they allowed them to practice the intervention’s parenting skills, despite not having their children under their care. One parent (participant #103) described this experience, “It was good. Because even though we didn't have our kids, we had the perfect example how to deal with that situation when we are around the children. So, you got to get a chance to check out everybody else's perspective, what their approach would be…So, it was good.” Similarly, a mother (participant #106) shared: I really like role-playing. I used to be involved in acting and I found it to be very therapeutic…and I think role-playing is just cool in itself because it allows people to see outside themselves. It allows people to have an imagination about something if they’re not sure. I just feel like the role-playing allows people to be interactive, hands-on… I think is really important in learning not just hearing, listening, but being able to take part… It just helps to break things down. Role-plays: Interventionists’ perspectives. Interventionists confirmed parents’ reports indicating the relevance of role-plays. Several interventionists discussed the importance of introducing role-plays with visual aids, as one interventionist (participant #202) affirmed: A lot of people, not just parents in general, are more visual. So when you go up and you show a parent ‘this is how it can look if you just try it. All you have to do is just try it. We’re not trying to say it’s gonna be perfect.’ Because some parents can’t read. For some parents it goes in one ear and comes out the other. But if they’re able to see what the skill is, they’re able to say ‘Oh ok, now I understand what you were saying. Now I get it.’ Interventionists also discussed how the use of role-plays often elicited unexpected emotions in parents, as one interventionist (participant #207) expressed: It allows for them to use the language and the approach that they are comfortable with. And it’s not something that they feel like is scripted. I’ve had parents tell me in role plays, ‘I almost, almost hit you in the face. I forgot we were in a role-play. That was so good. I forgot, you know.’ So, they’re able to lose themselves a little bit. I’ve had parents 75 cry. It really just helps to take all these concepts and ideas and give them real examples of what this looks like in real life because you can conceptualize them better. Home practice assignments: Parents’ perspectives. The majority of parents reported not implementing home practice assignments, as one mother (participant #105) admitted, “I didn’t do the homeworks, really. I didn’t say they didn’t help. I didn’t take the time to read or nothing. I just didn’t bother.” Parents often explained that they were engaged in the sessions, but rarely completed home-practice assignments, as one parent (participant #111) affirmed: I really came here to pay attention to the program. I am not going to say that I did the homeworks… why would I lie to you? But I can say that I came here to pay attention. That really is true. I liked to pay attention to what the [facilitators] were saying, not what it said in the paper. Some parents also disclosed having difficulties with completing home practice assignments because they did not feel they had enough time during their visitations to practice the skills. Learning disabilities were commonly reported as a barrier, as one mother (participant #113) explained: Well, when it came to read and write, I didn’t do that. I have a disability… But when it came to actually practicing with the children, yeah – I did that. I mean, don’t get me wrong, at the beginning, cause I didn’t have the child, I couldn’t practice it. But when I [finally] had the children, I was able to do it more. Home practice assignments: Interventionists’ perspectives. Interventionists confirmed that the majority of parents did not complete the home practice assignments, as one interventionist (participant #201) said, “I have only seen a handful of people ever actually do the worksheets…half of our people wouldn’t be able to do it even if they wanted to. Realistically, most of the parents don’t do them.” An interventionist (participant #203) also reflected on this issue: They [parents] just don’t do the home practice assignments. I think they feel like it is homework. We encourage them as much as we can, but we also know that they might 76 think, ‘I am not going to go outside of here and do homework to show someone else I did this. So, they’ll come in, they’ll talk about it, but to show us on the paper, no. Interventionists shared that parents might have practiced the skills at home, but did not complete worksheets aimed at tracking the implementation of the skill, as one interventionist (participant #206) affirmed: I think [parents] are doing it [home practice assignments]…but the actual paperwork material, I don’t think they’re doing it because of the fact that it is like another assignment….For some of the home practice assignments, they have to write and do things. Some of them [parents] are mentally ill or they don’t know how to write. But they may be practicing the skills. The Key Role of Interventionists Participants identified the role of the interventionists as critical for successful engagement, as well as for motivating them to remain committed to a process of change focused on their childrearing practices, interpersonal relationships, and coping skills. According to parents, the interventionists’ most important qualities consisted of their expertise in the intervention, their continuing support and kindness, and their overall ability to present the information in culturally and contextually relevant ways. One parent (participant #102) described the impact the interventionist’s understanding and support had on her engagement in the sessions: Ok, I ain’t messing with her. She’s good. She knows her shit. And like, she got me. And I flipped it. If others [parents in group] don’t care about their kids, I’m going to care about mine. I’m going to open my mouth. I’m going to participate.” Several parents also mentioned how meaningful it was for them to feel supported by interventionists and staff, particularly when facing challenging experiences, as one parent (participant #112) affirmed, “They would do nice things. They would reward us. And they would give good ideas. And they really never got us in trouble, they never ratted us out or anything like that.” A mother (participant #113) also explained: 77 They were supportive. They were very supportive. I just say we need even more of that. And there was always a person telling us to stay strong and not letting you get down, like ‘you're about break down on me, don’t do that, stay strong,’ they used to tell me, even though that’s a hard thing to do. When prompted, interventionists also reflected on the parents’ perceived importance of the interventionists’ role. Although these accounts were not as extensive as the ones provided by parents, interventionists discussed the importance of building trusting relationships with caregivers, as one interventionist (participant #204) said: I think part of it is that you have to be really transparent and real. They can smell you being fake. They can smell you being phony. They can smell you trying to teach them and talk to them versus at them. So, it’s all about on how you approach it. It’s all about how you facilitate. Because if you dismiss [them], then you’re dismissed as well. Parents’ Perspectives on their Process of Change: Parenting Practices A primary research objective referred to examining the applicability of Holtrop et al.’s (2014) process of change model as it refers to participants’ decision-making process related to the incorporation of new parenting practices. Of relevance, parents reported experiencing gradual changes in their parenting practices, resembling the phases described in Holtrop’s model. Specifically, parents described a process of change through which they first attempted the new skills, appraised their usefulness, and applied them. Similar outcomes were also observed, as parents either incorporated skills, adapted them, or set them aside. Finally, current findings indicate that ensuring contextual and cultural relevance was critical for participants to actively engage in a process of change. Attempt. Participants described the ways in which they initially attempted the new parenting practices as a way to examine their relevance. Role-plays were particularly helpful to achieve this goal, as one participant (participant #110) explained, “It was excellent to practice. That way you can go home and remember what to do. It’s a good way to learn.” Several parents 78 reported enjoying the role-plays because they could practice the new skills, knowing that interventionists would offer suggestions or identify important areas of growth. One mother (participant #102) affirmed, “Yes. Practice makes perfect.” A mother (participant #113) elaborated on these issues, “It was helpful to practice because if you’re doing it wrong, they will correct you right there and that for me was helpful.” Parents also reported attempting the new skills after reunification with their children. One mother (participant #102) shared her experience, “Sometimes, I used the tactics in the books with my kids to see if it worked. If she does something good, she gets rewarded. So, I tried it out.” A mother (participant #114) discussed practicing the skills with other children in her family: I practiced with my nephew. Since I only saw my children here at the office and they were always excited to play with the toys, it was hard to practice there. So, I practiced more with my nephews and nieces. I always praised my nephew when he did something well, thanks to this program. Now he shares when he does well in a test, I say, ‘Congratulations! Keep it up!’ He feels so happy. Appraise. In accordance with Holtrop’s model (2014), after initial attempts, parents engaged in a process through which they appraised the usefulness of the parenting practices and life skills presented to them. Parents discussed how they evaluated the skills and determined their usefulness and relevance. One mother (participant #109) shared her experience: As they talked about it, I started to understand why they took [my children] away… because of my attitude and behavior. Little by little, I understood. Not punishing your kid, but talking to him and removing a privilege works. Before I would just punish him and let him do whatever they wanted. Now, he listens. He even does his laundry and helps me out in whatever I need without complaining. A mother (participant #107) also reflected on the newly learned parenting practices, “You just have to try it. Take a walk, you know. It helps sometimes. If used correctly, it will work for you. But what you have to keep in mind is that you have to stay consistent, persistent, and determined.” 79 In contrast, if parents did not find the skills to be useful or applicable in their initial appraisal, they were less likely to incorporate the skills after completing the program. One mother (participant #106) affirmed, “When we took the classes, we would always joke in the class, ‘this is not going to work for our kids, it only works for White people.’ When I got my kids, I was like, ‘Damn, that stuff really didn’t work for our kids….’ So, it might work for some people, just not my kids.” A few parents reported discussing the skills learned in the intervention with trusted professionals or family members to help them appraise their usefulness. For instance, one mother (participant #101) disclosed talking to her therapist about the skills learned in group, “I always wanted to make sure it was right, that the therapist would also confirm what they were telling me in group. I wanted to be sure before practicing. I don’t trust anyone so I wanted to be sure.” Apply. Parents discussed engaging in the third step of the process of change proposed by Holtrop (2014), which refers to the ways in which parents applied the learned skills. Participants reported following three pathways with regard to the skills introduced to them: (a) applying the skills as they were presented to them, (b) adapting the strategies, or (c) setting the skills aside. For example, a parent (participant #111) reflected on applying the skills as learned in the program: I try to do the best I can. It was so hard to see my daughter with other people that weren’t her family. She said, ‘Bye bye mommy’ to the [foster mother]. But that’s not her mother. So, now I try to apply all the parenting stuff they talked about here so that I can be with my daughter and have a good relationship. I don't wish the way I was raised on anyone. So, my mentality changed. I want to have a different relationship with my daughter. I try to always apply [the lessons], even if it’s just a little bit. Several parents also discussed sharing the new skills with others. One mother (participant #114) affirmed that her use of the emotional regulation techniques became part of her life: 80 It’s like something that is stuck in my mind now. It is something I practice all the time, part of my routine, part of everything… I still have the books they gave us and sometimes I still check things. I even take pictures of the book and send them to my sister so that she can learn how to react with her daughters too. Parents also reported adapting some of the specific parenting skills according to their own personal, cultural, and contextual experiences. A mother (participant #107) affirmed, “I tried it the way it was, the way it was presented to me. But then I guess I added my own little flare to it.” A parent (participant #102) provided a similar reflection, “Remember there’s 150 ways you can teach a person how to do something. Regardless, if they’re different… So I said, ‘Ok. If this don’t work, I’m going to find a way that it does work.’ So, I am trying it out and adapting it.” Parents who set the new skills aside often reported considerable contextual challenges that impacted their ability to consistently apply the new parenting strategies. These parents often struggled with being a single parent and having several children under their care, experiencing health problems, or feeling overwhelmed with their children’s problematic behaviors. One mother (participant #112) shared, “I mean, it’s not easy. My son is difficult. He is very difficult. And, I mean, I’ve tried. I am still at the stage of trying with the new skills. But he is difficult.” A mother (participant #103) described her struggle trying to remember the parenting skills, “I have memory issues right now…I struggle a lot with my memory and I’m looking into something to help me keep track of a lot of different things. It’s terrible.” A single mother (participant #105) also explained, “I mean, hold on. It’s been a long time and I was part of the group when he got taken away from me. And my mind is like in having kids under my care now, so it is a little harder to remember a lot of stuff now.” 81 Intimate Partner Violence A key goal of this investigation was to examine the impact of IPV and coercive control on participants’ parenting practices and experiences in the PTC-R intervention. Although the majority of parents (n = 10) reported being single or separated, the majority of participants often discussed the impact of IPV on their lives and their children’s behaviors, particularly if the children had witnessed domestic abuse. For instance, one mother (participant #103) expressed: [My previous partner’s] parenting experience was abusive and then he tried to abuse me and I wasn’t trying to hear that. Because the child saw [the abuse], I have a long history of new behaviors to deal with. I wouldn’t wish it on my worst enemy for a child to witness domestic abuse. A mother (participant # 106) shared a similar struggle: My kids were taken away for 4 years. It’s been rough…My son witnessed a lot of the domestic violence when he was a kid. So, he is very violent towards his sister and in school, he is always hitting other kids. That probably has to do a lot with things that he saw, with learned behaviors from his dad… Perpetrators of domestic violence often use threats and coercive control to keep survivors from reporting the abuse. This issue was addressed by participants, as one immigrant mother (participant #109) reported her experience: I experienced domestic violence here, but because I was afraid, I never spoke up. My child’s father would beat me with his belt. In front of people, he would pull my hair. He would hit me wherever he wanted and he abused me. He treated me like an object. I never called the police because he said that if he ever got deported, he would kill my mother and my oldest son, who are both in my home country. I finally reported him and he is now trying to convince me that he has changed, that I should drop the case. But I don’t forget. We are going to court. Parents also discussed challenges associated with having to co-parent with abusive expartners. One mother (participant #105) shared her story: No, I don’t co-parent. [My child’s father] is mental. I didn’t know he was like that or I would have never got with him. The type of personality he got, he gets mad easy. The things that come out of his mouth... He told me one day if I ever came to his mother's 82 house with a different guy than him, he'll kill me and the boy. I said, ‘I'm not scared of you. Don't threaten me. Don't talk about my son.’ A mother (participant #107) described the grief and anger she has experienced for having to co-parent with an abuser: No, we are not in sync. It’s upsetting. It hurts to some extent. We have these children and even though I'm doing my part as their mother, he's supposed to have like some type of positive influence in these children's lives. And when I see that that’s not going on, it infuriates me…There's a lot of things that he'll do in front of them that would make me say, ‘well, how are these children gonna grow up to be if they see you being, disrespectful to their mother, cursing their mother out. What type of women, will my girls grow up to be, if they see their father treating their mother like that? Or what type of men will my boys grow up to be, if they see their father treating their mother like that? In contrast, the majority of interventionists did not overtly identify intimate partner violence as a prevalent issue impacting parents’ experiences in the PTC-R interventions, as one interventionist (participant #206) shared, “An issue like that hasn’t been brought up maybe because we’re not asking those type of questions…” However, some interventionists reported contacting case workers and scheduling partners to different intervention groups if IPV or coercive control issues were suspected, as one facilitator (participant #202) shared, “If we suspect or we know that there may be IPV, we try to ask for them to be in two different groups – ‘you take the one in September and you take the one in November…’ If they’re in the same group, then you just have to watch them very carefully.” Additional Areas of Improvement: Increased Attention to Cultural and Contextual Issues Participants’ perspectives. Although participants expressed satisfaction with the PTC-R intervention, they stressed the importance of overtly addressing cultural and contextual experiences that have a considerable impact on their parenting efforts. Specifically, when asked to offer specific recommendations to improve the cultural and contextual relevance of the parenting program, participants referred to issues of discrimination, immigration, and cumulative 83 trauma. Discrimination. Parents stressed the importance of overtly discussing issues of discrimination in the parenting program, particularly to gain the necessary skills to talk with their children about these sensitive topics. One mother (participant #103) expressed: We shouldn’t be waiting for our kids to get in a fight or something big to blow up in school or something big to happen to [talk about] the reality of the years of slavery that went on in this country, the discrimination that constantly goes on, that my child has witnessed growing up. [We should talk about] the real life stories of what goes on – what parents experience, what families experience – and then tailor parenting [topics] around that. Another mother (participant #104) also affirmed: I think the topic of discrimination is very important right now. It would be good if we could expand on that more - to try to find the way for our children not be discriminated against at school and for them to not discriminate against others, so that we can promote equality among the children, but also among adults. Several parents expressed that by overtly discussing issues of discrimination in the intervention, parents could benefit by sharing specific coping strategies. One parent (participant #107) suggested, “I would just let the individuals in the class know that it's not your fault when people act like that. It has nothing to do with you why they act like that. I would just basically let them know: don't take it on.” A mother (participant #113) also suggested that it would be helpful to openly discuss issues of discrimination in the parenting group for parents to support each other: It’s good when you hear other people talking, other parents, cause they´re the same. Everybody has different opinions, and its good to just listen to what everybody´s going through ’cause it makes you stronger. It makes it seem like hey, you're not the only one that’s going through it… So, it’s good for all the parents to hear other parents. You’re not fighting the world by yourself. Immigration. Half of the parents in the study self-identified as immigrants. The majority of these parents mentioned the importance of discussing immigration-related themes in addition 84 to issues of discrimination. One parent’s reflection (participant #110) illustrates the sentiment expressed by other immigrant parents in the study, “There is so much difference. As Hispanics, we have to adapt to this system and remember that we are no longer in our countries, we are here now.” Immigrant parents also expressed an interest in overtly addressing discrimination, as well as discussing their rights as immigrants. One parent (participant #111) affirmed: I would like it if we talk more about us as immigrants, about our rights. Because sometimes you go to get a job and because you’re Hispanic or because you look like you might not have papers, you get discriminated against. So, it would be good if they explained to us how to address the situation, how to react, so that it doesn’t affect you that much… because if you don’t have the knowledge, it’s like being completely disarmed. Cumulative Trauma. The majority of parents discussed the challenging and traumatic nature of an ACS removal for both, parents and children. In addition, parents often addressed the challenges of reunification, particularly when their children returned home after a long period of time. One parent (participant #106) stated: [My daughter] changed a lot after foster care. I learned that you have to be patient because it's something that not only upsets parents but damages children...they can become traumatized. It's a big deal to be in foster care. It's a big deal to lose your kids too. But it is even worse when you get them back and you don't even know each other, like we have to like get to know each other again. It's complicated... Several parents discussed the trauma experienced by children being involved in CWS, as one mother (participant # 103) disclosed: If I didn’t go to any kind of counseling, I would have no clue to expect traumatization in my kids. If someone is traumatized they’re not showing at you every minute. You might have someone showing you every minute, where someone else is not. I didn’t know what to expect. I didn’t know what it looked like. I didn’t know the name to call it. So, not being able to identify what’s going on with your child is hard if you have no knowledge. In addition to experiencing considerable distress as a result of experiencing the removal of a child by ACS, the majority of parents discussed the multiple and severe challenges they have endured, including experiencing poverty, intimate partner violence, and childhood abuse. A 85 mother (participant #106) disclosed “My kids were taken away for four years. It was for domestic violence and then, I admitted that I smoked marihuana, so that became like another barrier for reunification.” One mother (participant #112) reflected on her childhood traumatic experiences as she navigated parenting her own children. She shared: My mother left on my seventh birthday. She was abusive too. Mostly hitting us, trying to make us be quiet. But with my kid, I can't do that. I can't be like my mother, you know? Cause I mostly remember everything…What she put us through, how she did things with us that I felt she shouldn't have done that way, you know? Finally, several parents shared the challenges associated with living in poverty and experiencing housing challenges, as one mother (participant #103) explained: I was already going through years of [housing] harassment…every three or six months I’m in court for whatever the landlord said. He could use anything. It should have been a construction eviction but it was looked at as a money-owed type of thing. It wasn’t about owing money as it was the fact that my landlord was trying to run me out of my apartment by not fixing nothing. So, every minute, I have a repair issue going on where I have to organize my day around it. Interventionists’ perspectives. Interventionists offered specific suggestions to increase the cultural and contextual relevance of the intervention and ensure a close fit with the population they serve. Specifically, they highlighted the need for the following adaptations: (a) refining the language of intervention materials, (b) adding the monitoring and supervision component adapted according to culture and context, (c) overtly addressing corporal punishment when delivering the limit setting component, and (d) offering a clear distinction between problem solving and conflict resolution. Language. All interventionists reported modifying the language of materials, scripts of role-plays, and examples used in the PTC-R curriculum to ensure the cultural and contextual relevance of the intervention. Interventionists highlighted the need for role-plays and examples to reflect the reality of low-income ethnic minority parents living in New York City, as one 86 interventionist (participant #202) recommended, “I would make the language more suitable for the community to make it culturally appropriate and the examples more related to New York City.” Interventionists also expressed the need to revise the language used in home practice assignments to better reflect the experiences of parents who had their children removed from their homes. One interventionist (participant #204) explained, “It shouldn’t be called a home practice because parents are not going home to practice it. They’re coming to a visit to practice it, so I don’t like saying home practice. I just say - Practice this is in your visit.” An interventionist (participant #207) expressed her concern about the term and offered a suggestion, “This idea of calling it a ‘home practice,’ I think is very disrespectful to the families, knowing that they cannot go home to practice this, because the kids are not home with them. The language should reflect their reality. So it should be family-time practice or family practice.” Monitoring and supervision. The monitoring and supervision component is addressed in the PTC-RH intervention once children are reunified with their biological families. However, interventionists discussed the relevance of adding this component to the PTC-R curriculum, prior to reunification. When asked for specific suggestions, the majority of interventionists expressed clear consensus about the importance of adding this component to the PTC-R curriculum, as one interventionist (participant #204) affirmed, “I think it’s important for monitoring to be included into the PTC-R curriculum”. Two interventionists (participant #206 and #207) concurred, “I would try to incorporate monitoring to PTC-R” and “I would bump up monitoring.” Corporal punishment. The majority of interventionists expressed the need to overtly address issues associated with corporal punishment when introducing the limit setting component. Specifically, interventionists discussed how parents often discussed their 87 experiences with corporal punishment as children and expressed resistance to engaging in nonpunitive limit setting strategies with their own children, due to concerns that mild consequences would not build their character or would not prepare them for a hostile world. Thus, interventionists reflected about the challenges resulting from overtly addressing these issues with parents, as one interventionist (participant #201) explained: The discipline piece is not well received. When we have conversations about time-out parents think it’s a weak and ineffective strategy. We constantly get the ‘Well I was beat as a kid and look how great I turned out’ and they are not saying it sarcastically. We try to get them to understand that corporal punishment works in the moment but it doesn’t work long term…we try to get them to be a little insightful. It’s frustrating. An interventionist (participant #207) further elaborated on these issues: Corporal punishment is part of limit setting for the majority of the cultures that we serve. They want to talk about it. They need to talk about it so that we can move on to this idea of time out and privilege removal. We need language so that we can talk about this…We sometimes call it - physical intervention and we talk about the fact that that is effective in the moment. It takes 20 or 30 minutes and then we can get to the alternatives to hitting. But we have to have that conversation. We need something to reference to have this conversation when they bring it up. They’re going to bring it up. Conflict resolution and problem solving. The distinction between these two concepts was challenging for interventionists and parents to understand. Therefore, interventionists suggested making modifications to the way these concepts are presented, as one interventionist (participant #204) expressed, “I feel like conflict resolution should be defined a little nicer for you to be able to teach it.” Interventionists also expressed needing more time to make distinctions between the two concepts, as one interventionist (participant #208) affirmed, “I would like a little bit more time for conflict resolution and problem solving.” 88 CHAPTER 5: DISCUSSION The main goals of this investigation were to explore the cultural and contextual relevance of the PTC-R intervention and examine the process of change experienced by a group of lowincome ethnic-minority parents involved in CWS, and who were exposed to the parenting program as a requisite for reunification with their children. To accomplish these research goals, individual interviews were conducted with PTC-R interventionists and low-income ethnic minority parents who successfully completed the intervention, were reunified with their children, and were discharged from mandated services at the time of the interviews. In the following sections, research findings will be analyzed in light of existing literature, followed by a discussion of limitations and strengths of the study. Implications for research and family therapy practice are also discussed. The Prominence of Culture and Context The current study confirmed the need to thoroughly address cultural and contextual issues when conducting adaptations of PT interventions for dissemination with underserved ethnic minority populations. According to the data, the adaptations implemented by interventionists were essential to enhance participants’ motivation to remain engaged in the parenting program. The interventionists’ perceptions corresponded with those provided by parents, as caregivers described with precision the intervention components that were most relevant to them, as well as those that they considered were not applicable to their parenting practices. These findings confirm the need to recognize that culture and context, rather than being considered complementary variables to refine interventions, constitute key determinants for the overall relevance of interventions for diverse families, particularly if target families are mandated to participate in mental health services (Kotchick & Forehand, 2002; Parra-Cardona et al., 2015). 89 ACS context. Current findings provided useful insights regarding the impact of experiencing the removal of a child by CWS. In this particular study, child welfare services were represented by the Administration for Children Services (ACS). Although removal experiences are intended to ensure the safety and wellbeing of children, they also constitute extremely challenging life events for affected families. Specifically, parents in this study reported high levels of stress, anger, and anxiety associated with their involvement with ACS. These findings align with prior reports documenting that parents involved in CWS are exposed to disproportionately high rates of mental health problems, substance use, stress, and poverty (Barth et al., 2005; Jimenez & Chambers, 2009). Thus, in addition to working on specific parenting goals for reunification (e.g., parents embracing non-punitive parenting practices), a focus on promoting overall mental health among caregivers is essential. Such a goal is particularly necessary when considering the multiplicity of stressors faced by parents as they attempt to meet requirements for reunification (Jimenez & Chambers, 2009). The narratives provided by interventionists also correspond with parents’ accounts describing the impact of stressors resulting from their involvement in ACS. This issue is of particular relevance when considering the high dropout rates of parents mandated to complete parenting programs as a requisite for reunification (Barth et al. 2005). Based on the limited number of existing culturally relevant efficacious PT interventions for families mandated to parenting services, the cultural adaptation process of these interventions must be informed according to a thorough understanding of the complexities of CWS. Specifically, there must be recognition of the stressors associated with the removal of a child by ACS (Berard & Smith, 2008; Casanueva et al., 2012; Franks et al., 2013; Jimenez & Chambers, 2009) and the potential 90 challenges associated with an average removal period of two years or longer (A. Muñoz, personal communication, June 2017). Parenting in context. Current findings highlight the importance of addressing the challenging childrearing context that low-income ethnic minority families involved in CWS often experience. For example, the majority of parents in this study reported their annual family income to be below the federal poverty level. Thus, parents provided detailed descriptions of the challenges associated with parenting while experiencing poverty in New York City, including living in undesirable and unsafe neighborhoods, having difficulty attending weekly visitations due to the costs associated with those visits, or lacking the social support networks needed to decrease parental stress. These results correspond with previous research indicating that parents involved in CWS are exposed to disproportionate rates of poverty and stress (Barth et al., 2005; Jimenez & Chambers, 2009). Further, these findings highlight the importance of recognizing parents’ context and circumstances when delivering PT interventions to underserved populations exposed to multiple contextual challenges. The role of social support. Parents provided detailed narratives indicating the positive impact of connecting with other parents who were experiencing similar life challenges. These results confirm previous research indicating the importance of promoting social networks for underserved diverse populations as they participate in PT interventions (Green, Furrer, & McAllister, 2007), particularly as it refers to reducing isolation and stigma (Kemp, Marcenko, Hoagwood, & Vesneski, 2009). Studies also indicate that enhancing social support networks constitutes a key protective factor against child abuse and neglect among populations exposed to chronic contextual stressors (Holtrop, McNeil, & McWey, 2015; Mejia et al., 2015; Myers et al. 1992, Stith et al., 2009). 91 Discrimination. Detailed accounts provided by parents highlight the need to overtly address issues associated with discrimination in PT interventions adapted for underserved ethnic minority populations (Ayon, 2013; Kotchick & Forehand, 2002; Unger, 2015). This is particularly important for parents involved in court-mandated services, as they are likely to be concerned about openly addressing these issues due to fear of retaliation or dismissal of their experiences. In the current study, parents expressed a desire to openly address discrimination, ranging from personal experiences to perceptions of the current US socio-political climate. These findings align with calls by scholars that highlight the importance of overtly addressing oppression, racism, and discrimination in all facets of parenting interventions (Baker et al., 2011; Bogart et al., 2013, Coard et al., 2007; Williams & Mohammed, 2009; Parra-Cardona et al., 2017). Current results are particularly timely when considering the recent surge of expressions of White supremacy and anti-immigration rhetoric throughout the US, which have resulted in increased rates of hate crimes and other forms of discrimination toward diverse populations (Paluck & Chwe, 2017; Southern Poverty Law Center, 2016). Findings according to ethnic self-identification. Current findings did not indicate differences according to ethnic self-identification. That is, there were no noticeable differences on themes reported by Latinx and African American parents. The only contrasting theme referred to immigration issues reported by Latinx immigrant parents. Specifically, these participants expressed a desire to discuss experiences associated with the challenges of adapting to a new culture, while also learning to navigate systems that they consider sharply contrast with those of their home countries. The uniformity of experiences found in non-immigration topics may be due to the multicultural nature of NYC, in which ethnic self-identification is not as prominent as it is in other regions of the country (A. Muñoz, personal communication, August 2015). Of interest, 92 the majority of parents in this study expressed significant challenges resulting from their status as ethnic minorities, which was related to various types of experiences of discrimination in a variety of settings. These findings are relevant as they indicate the need to inform PT interventions for underserved ethnic minorities according to principles of racial socialization practices. This approach continues to be scarce in the PT literature and should be expanded (Caughy et al., 2002; Hughes et al., 2006). Intimate partner violence. Although the majority of parents in this study reported their marital status as single, several mothers self-identified as survivors of intimate partner violence (IPV). In some cases, caregivers also reported that children had witnessed the abuse they experienced. These results are consistent with prior research indicating that approximately 30% of all children involved in CWS have a female caregiver who has reported recent exposure to IPV (Hazen et al., 2004). However, interventionists did not express clear consensus with regard to their perceptions of the potential impact of previous experiences of IPV in parents’ participation in the PTC-R intervention. These findings are relevant as IPV is rarely addressed in the PT literature, which constitutes an issue of serious concern when considering that parenting interventions can significantly increase the risk for IPV. Thus, there is a high risk for harm if PT services are offered without a thorough understanding of IPV processes, including knowledge of the best screening and intervention practices (Houry et al., 2006; Kelleher et al., 2008, Russell et al., 2010). Further, mothers discussed the multiple and serious challenges associated with coparenting with an abuser. These findings are in line with the extensive literature documenting the many ways in which abusers utilize coercive and intimidating tactics to control their partners and children. Some of these tactics include sabotaging the survivors’ parenting efforts, creating a 93 false impression in children by depicting the abuser as the ideal parent, or turning children against their mothers (Edleson & Williams, 2007; Bancroft & Silverman, 2002). Therefore, current findings highlight the urgent need to offer PT interventions according to IPV-informed best practices, particularly with populations exposed to multiple contextual challenges that may impede their capacity to access the resources and support they need when facing abuse (Bybee & Sullivan, 2002; Greeson et al., 2014). Perceived Relevance of PTC-R Intervention Qualitative narratives of parental satisfaction with the PTC-R intervention constitute a relevant contribution to the literature, particularly when considering the scarcity of qualitative research focused on PT interventions with low-income diverse families involved in CWS (Barth et al., 2005). Current findings align with prior research indicating that PT programs for biological parents of children involved in CWS have positive effects on the quality of their parenting skills and overall parent-child relationships (Berard & Smith, 2008; Franks et al., 2013). In this investigation, parents identified the following three GenerationPMTO core components as highly relevant to their parenting efforts: (a) limit setting, (b) skills encouragement, and (c) positive involvement. Further, participants identified emotional regulation, active communication, and good directions as highly salient to their parenting efforts, as well as relevant to their interpersonal relationships and personal coping skills. Limit setting. Participants in this study identified limit setting as the most relevant intervention component for their parenting efforts. These findings correspond with metaanalytical data indicating the positive impact of limit setting across populations representing contrasting contexts and cultural backgrounds (Kaminski et al., 2008; Michelson et al., 2013; 94 Vlahovicova et al., 2017). Participants also specified that privilege removal was their preferred limit setting skill based on its relevance and high applicability to their daily parenting practices. Current findings contrast with existing research indicating that various populations, including underserved low-income ethnic minorities, perceive the time-out procedure to be a useful limit setting strategy (Baumann et al., 2014; Bjøknes, et al., 2012; Forgatch & Patterson, 2010; Kaminski et al., 2008; Parra-Cardona et al., 2017). Several explanations may clarify this issue. First, this investigation contrasts with previous GenerationPMTO trials as it was conducted with a sample of low-income parents living in a large urban setting and exposed to intense stressors, including considerable housing challenges. For example, interventionists reported that key adaptations were made when introducing time-out in an effort to match the living arrangements of participants (e.g., single lofts without separate rooms). Further, parents were exposed to the PTC-R intervention while their children were not under their care. Due to the complexity of the time-out procedure, this issue represents a highly significant challenge, as parents did not have the opportunity to implement the time-out procedure on a consistent basis. In addition, parents reported the many challenges associated with learning to implement a complex technique, such as time-out, while having minimal social support to remain responsive to the needs of many children. This lack of social support represents a considerable barrier for learning the time-out procedure. Competing demands for caring for several children limit the possibilities for parents to focus their attention on one child, particularly in the beginning phases of learning the technique. This issue corresponds with research suggesting that time-outs are most effective when parents have adequate social support (Green et al., 2007). Further, current findings correspond with results from studies with low-income Latinx populations highlighting the importance of considering dosage and pace of delivery when teaching complex parenting 95 skills. Specifically, researchers have reported the need to considerably slow the pace of delivery of complex GenerationPMTO components by addressing them through multiple sessions, particularly if parents are exposed to severe contextual challenges and literacy limitations (ParraCardona et al., 2016). Finally, it may be possible than even when addressing the aforementioned issues, the time-out technique may not be culturally relevant for specific populations, suggesting the need to prioritize the target population’s cultural preferences (Bernal & Saez-Santiago, 2006; Kotchick & Forehand, 2002). Skills encouragement. Parental satisfaction with the skills encouragement component confirms previous findings indicating the relevance of this component when delivered to underserved diverse populations (Bjørkes & Manger, 2013; Holtrop et al., 2014; Parra-Cardona et al., 2017). However, qualitative narratives also indicate that parents’ satisfaction was primarily related to the concept of encouragement and the use of the most basic skills related to incentivizing good behavior. Of interest, participants expressed difficulties understanding and implementing the token system, which is a main encouragement tool taught in the PTC-R intervention. A possible explanation for the lack of relevance of the token system might refer to the complexity of the technique itself, as suggested by interventionists. This finding is relevant, given that it resembles findings associated with the time-out sequence. Current data indicate that although parents liked the principles of this core component, they also considerably struggled when incorporating and implementing the more complex encouragement techniques. Parents emphasized the challenges associated with not being able to directly implement some of the techniques prior to being reunified with their children. Thus, current findings highlight the importance of cultural adaptation throughout the intervention delivery process to ensure a strong contextual and cultural fit with target populations, particularly if they are exposed to multiple 96 contextual stressors, including the lack of daily interactions with their children (August, Gewirtz, & Realmuto, 2010; Bernal & Saez-Santiago, 2006; Domenech Rodriguez et al., 2011). Positive involvement. Participants expressed high satisfaction with the positive involvement component, suggesting the relevance of these principles for low-income ethnic minority parents involved in CWS. These results align with meta-analytic findings indicating the high relevance of positive parent-child interactions for both parents’ and children’s behavioral outcomes (Kaminski et al., 2008). Further, current findings are consistent with previous investigations reporting high participant satisfaction with this component (Bjørkes & Manger, 2013; Parra-Cardona et al., 2015; 2017). Monitoring and supervision. Although this core component was not originally included in the PTC-R curriculum, Coalition leaders decided to include relevant principles in the intervention. Overall, the skills of this component were identified as highly relevant by both parents and interventionists. Specifically, interventionists reported weaving in key monitoring and supervision concepts throughout the intervention due to the strong relevance of these principles for the target population. Current findings are significant when considering that more than 60% of child removal cases in CWS are related to allegations of child neglect (Barth et al., 2005; DHHS, 2016). Thus, participants reflected about the many ways in which deficient monitoring and supervision can lead to child neglect, highlighting the relevance of the skills outlined in this intervention component. This finding is an important contribution to the literature as it underscores the prominence of addressing this topic in PT interventions for child welfare populations (Casanueva et al., 2014). Problem solving. Although interventionists reported the relevance of this component, problem solving was rarely identified as relevant by parents in this study. These findings contrast 97 with prior research indicating that problem solving skills are an important precursor of effective parenting (DeGarmo & Forgatch, 2004; Forgatch et al., 2009). In studies with low-income Latinx immigrant populations, this component has been found to be particularly useful to promote family cohesion and increase cultural understanding among family members (ParraCardona et al., 2015; 2017). However, in these specific studies with low-income Latinx immigrants, problem solving skills were adapted to purposefully promote engagement in desirable family routines and rituals (e.g., planning a fun family night). This adaptation was conducted after a few instances in which parents selected challenging situations that led to parents’ dissatisfaction with the original problem solving component (Parra-Cardona et al., 2015). Taking into consideration the intense adversity experienced by parents in this study, it may be possible that this type of adaptation was needed to increase the cultural and contextual relevance of the component for this population. Finally, interventionists expressed struggles associated with the fact that this component was delivered last in the curriculum, prior to the participants’ graduation ceremony. Current findings highlight the need to consider delivering this component early in the curriculum to provide interventionists with sufficient time to troubleshoot challenges of implementation. GenerationPMTO supportive components. Qualitative narratives indicate that emotional regulation, active communication, and good directions were relevant to participant parents. These findings confirm previous research reporting the saliency of these components across various contexts and populations (Forgatch & Domenech Rodriguez, 2016; Forgatch & Kjøbli, 2016). Further, narratives from parents and interventionists indicate the positive impact of the emotional regulation and active communication components, as their application extended beyond parenting practices and improved the quality of participants’ interpersonal relationships 98 and personal coping skills. These findings are supported by recent research indicating that emotional regulation and active communication principles have an additional benefit consisting of helping parents enhance the quality of their interpersonal relationships, reducing stress, and enhancing anger management skills (Coatsworth et al., 2010). Current findings underscore the need to remain attentive to the applicability and usefulness of the intervention for the enhancement of caregivers’ interpersonal skills beyond parent-child interactions. For example, parents reported that learned skills were instrumental to improving their interpersonal skills as they engaged in multiple interactions with CWS staff. Therefore, current findings highlight the importance of remaining aware of the benefits of parenting skills as they extend beyond specific parenting goals, particularly for populations mandated to services and required to interact with multiple and challenging systems (Casanueva et al., 2014; Hines et al., 2004). Intervention delivery methods. Parents identified role-plays as an important learning tool that allowed them to master the skills presented in the PTC-R intervention. Parents also emphasized the usefulness of role-plays given that they did not have their children under their care at the time of their involvement in the parenting program. This finding confirms previous research indicating the numerous benefits of this teaching method and its cross-cultural relevance (Holtrop et al., 2014; Forgatch & Patterson, 2010; Knutson et al., 2003). These findings are particularly relevant when considering the specific challenges experienced by families served by CWS (Casanueva et al., 2014; Hines et al., 2004). Home practice assignments (HPA) are considered an important delivery strategy in the GenerationPMTO literature (Forgatch & Domenech-Rodriguez, 2016). However, current qualitative data indicate that most participants did not experience HPAs to be relevant nor applicable. This is an important finding given the limited scholarship on the impact of HPAs in 99 PT interventions (Holtrop et al., 2014; Kaminski et al., 2008). As it was the case with previous techniques that were not considered applicable by parents, it appears that the lack of relevance was a result of insufficient fit between the technique and participants’ challenging contextual realities. This constitutes an important area of refinement of the intervention because even though HPAs were designed for parents who had experienced the removal of a child, findings indicate that the applicability of the HPAs was limited. The key role of interventionists. Current findings highlight the role of interventionists as a key element for ensuring the successful engagement and retention of participants in mandated PT programs. Specifically, parents noted the critical role of the interventionists’ expertise, warmth, and ability to frame information according to salient cultural and contextual experiences. These findings confirm previous research indicating the importance of a strong collaborative relationship between interventionists and participants (Forgatch & Martinez, 1999; Patterson & Chamberlain, 1992), as well as the need for interventionists to frame the intervention’s material in cultural and contextually relevant ways (Domenech Rodriguez et al., 2011; Domenech-Rodriguez & Wieling, 2004). Current data also corroborate principles of joining as an important element of change across various modalities of therapy, as indicated in the common factors literature. That is, a strong therapeutic alliance is a critical precursor of change across interventions, regardless of the focus of the intervention and target population (Blow, Sprenkle, & Davis, 2007). Therefore, current findings highlight the importance of continuing to monitor ways in which this process is promoted and improved when delivering PT programs to diverse families in child welfare contexts (Barth et al., 2005). 100 Parents’ Process of Change This investigation adds valuable information to the growing scholarship focused on examining parents’ perspectives of their experiences in evidence-based PT programs, particularly when considering the extent to which they incorporate, or not, specific parenting skills. Further, this study is innovative considering the limited number of studies focused on examining the process of change of biological parents mandated to participate in PT based on their involvement in CWS (Barth et al., 2005; Gardner et al., 2016; LaGreca et al., 2009; Sandler et al., 2011). This investigation is also relevant as there is a scarcity of qualitative investigations aimed at exploring parents’ perceptions of intervention components and the decision-making process leading to the incorporation, adaptation, or rejection of learned parenting skills (Holtrop et al., 2014). Of interest, current findings indicate a process of change similar to the one described by Holtrop et al. (2014). Qualitative narratives suggest that parents attempted, appraised, and applied intervention skills as they were gradually exposed to them. Resembling Holtrop’s findings, this process was characterized by parents’ intentional efforts to evaluate the usefulness of the parenting practices within their own life contexts. Data also indicate the different pathways parents followed when making final decisions regarding the incorporation, adaptation, or rejection of parenting skills. Of interest, data indicate that skills that were set aside were those identified by parents as irrelevant to their contextual and cultural realities or were too complex to implement. Therefore, critical areas for future research include the need to identify whether the rejection of skills that are associated with the efficacy of PT interventions are due to their lack of relevance or, in contrast, to deficiencies in the cultural adaptation process that may not have been 101 fully responsive to the contextual and cultural realities of the target population (LaGreca et al., 2009). Study Limitations and Strengths Important limitations of the study must be noted. First, recall bias may have impacted the quality and precision of data, given that interviews were not conducted immediately after parents completed the intervention. In addition, due to the multiplicity of contextual challenges experienced by parents (e.g., cumulative trauma, post traumatic stress, discrimination, intimate partner violence), findings may have been influenced by challenges negatively affecting parents at the time of the interviews. It is also possible that participants had difficulty recalling and implementing the new parenting skills due to these multiple and complex challenges. Further, only parents who completed the PTC-R intervention, reunified with their children, and were discharged from ACS were eligible to participate in this study. Thus, this investigation only captured the experiences of parents who successfully completed the PTC-R intervention and court-mandated services. This is a key limitation given that the experiences of parents who did not meet these inclusion criteria were not captured. Notwithstanding current limitations, this investigation offers important contributions to the literature on cultural adaptation and implementation of PT interventions for biological parents involved in CWS. Specifically, current findings address a gap of empirical knowledge related to the experiences of low-income ethnic minority parents exposed to evidence-based parenting interventions in CWS (Barth et al., 2005). Study findings also build on existing knowledge regarding the multiple ways in which parents implement, adapt, or set aside skills learned in PT interventions (Holtrop et al., 2014). This knowledge is useful to inform the evolving scholarship focused on mechanisms of change and mediating effects of parenting 102 practices on child outcomes (Eddy & Chamberlain, 2000; Forgatch et al., 2016; Gardner et al., 2006). Finally, the strong correspondence of narratives between parents and interventionists underscore the importance of cultural adaptation, particularly when delivering interventions to low-income ethnic minority parents exposed to considerable contextual and cultural challenges, including CWS involvement (August et al., 2010; Casanueva et al., 2012; Castro et al., 2010; Domenech-Rodriguez & Wieling, 2004; Jimenez & Chambers, 2009; Kotchick & Forehand, 2002). Implications for Research The results of this investigation have relevant research implications. First, it is estimated that nearly half of the biological parents involved in CWS and who enroll in PT programs, fail to complete them (Barth et al., 2005). Therefore, more research is needed to further understand the multiple contextual, programmatic, and service delivery barriers associated with these attrition rates, as well as key improvements that service providers can introduce to systems of care to address these issues. Current findings clearly indicate the central role of cultural adaption processes to ensure the contextual and cultural relevance of PT interventions, particularly if they are delivered to populations experiencing considerable hardship. In this study, adherence to the original curriculum without key adaptations conducted by interventionists would most likely have resulted in high program attrition. Further, it is possible that insufficient cultural adaptation could have led to specific intervention components being considered irrelevant or not applicable by parents. Thus, refining design and adaptation protocols in future GenerationPMTO studies is essential to gather data aimed at determining the relevance of core and supportive components after they have been thoroughly adapted according to context and culture. This characteristic of 103 the cultural adaptation research process should be a priority, as there is always a risk to minimize or overlook the expertise of community partners, particularly when considering that such expertise is the result of extensive engagement and knowledge of target communities. Thus, close and permanent collaboration with community partners and key community leaders is essential when implementing PT interventions in underserved settings to thoroughly ensure the cultural and contextual relevance of adapted interventions (Domenech-Rodriguez et al., 2011). It is also critical to identify specific contextual and cultural themes that are likely to enhance the cross-cultural relevance of PT components across multiple underserved populations. For example, the use of emotional regulation strategies to help parents cope with the effects of discrimination and racism is likely to enhance the impact of this component when delivered to diverse communities experiencing intense contextual stressors. An additional example refers to the importance of discussing corporal punishment when introducing limit setting sessions, particularly if corporal punishment narratives are embedded within larger cultural narratives that normalize harsh or punitive childrearing practices. Thus, carefully evaluating the impact of such precise adaptations is essential to help promote cross-contextual and cross-cultural lines of scholarship that would allow for a generation of research that is not limited to single population studies. Results from this study also underscore the multifaceted needs of underserved populations involved in child welfare services. Specifically, families in CWS are often in high need of multiple services, such as legal support, mental health, financial aid, housing, and domestic violence assistance (Casanueva et al., 2014; Hines et al., 2004). Current findings indicate the need for a comprehensive advocacy approach aimed at enhancing the impact of efficacious PT interventions. Therefore, it is important to gain a clearer understanding of the 104 complex needs of families involved in CWS to design integrative intervention approaches aimed at addressing their most significant needs. Further, current findings emphasize the deleterious impact of IPV on children and mothers (Casanueva et al., 2014; Hazen et al., 2004; Greson et al., 2014). Thus, it is essential to better understand how experiences of IPV and coercive control negatively impact survivors’ participation in PT programs and ability to utilize particular parenting strategies. By overlooking attention to these issues, there is a high risk that PT programs may inadvertently exacerbate IPV and cause further harm, particularly among populations where IPV is often underreported (Hien & Ruglass, 2009; Lipsky et al., 2012; Rizo & Macy, 2011; Waller et al., 2012). Lines of scholarship that focus on informing the delivery and implementation of efficacious PT interventions according to IPV considerations are sorely needed. Finally, the results of this investigation highlight the importance of continuously monitoring the fit between intervention components and participants’ values, worldviews, and context (Bernal & Saez-Santiago, 2006). Based on these considerations, differential cultural adaptation and implementation science studies hold great promise to help us understand the minimal and precise adaptation requirements that are necessary to achieve high implementation feasibility, efficacy, and cultural and contextual relevance (August et al., 2010; Parra-Cardona et al., 2017). These types of studies are scarce in the CWS literature with mandated low-income populations and although challenging to implement in practice, they would provide valuable evidence about how to maximize the delivery of interventions while ensuring their relevance for target populations. 105 Implications for Family Therapy Important implications for family therapy practice can be drawn from this study, particularly as it refers to prevention and clinical services for this population. Current findings highlight the relevance of using evidence-based PT interventions as a key alternative to addressing the widespread mental health disparities that impact low-income ethnic minority families. However, the use of evidence-based interventions among family therapists serving diverse populations exposed to multiple contextual challenges is not yet uniform (Minuchin, Colapinto, & Minuchin, 2007). Research efforts led by Bernal and colleagues (see Bernal & Domenech-Rodriguez, 2009; Bernal, Jimenez-Chafey, & Domenech-Rodriguez, 2009; Bernal & Saez-Santiago, 2006; Domenech-Rodriguez et al., 2011; Domenech-Rodriguez & Bernal, 2012; Smith et al., 2011) have been critical to extend these principles to better support low-income ethnic minority populations. Working collaboratively with underserved diverse populations, Bernal and colleagues developed a systematic adaptation framework to ensure the cultural and contextual relevance of evidence-based treatments. Multiple applied studies have demonstrated the positive impact of using this framework for the cultural adaptation of efficacious interventions (DuarteVelasquez, Bernal, & Bonilla, 2010; Orellano-Colon, Varas-Diaz, Bernal, & Mountain, 2014; Parra-Cardona et al., 2012, 2017). However, there is still no uniform empirical evidence indicating the extent to which the use of evidence-based practices in family therapy is thoroughly informed by cultural adaptation frameworks to ensure the contextual and cultural relevance of delivered interventions (Bernal, 2006; Domenech-Rodriguez & Wieling, 2004). Following this order of ideas, family therapists aiming to work with low-income diverse families involved in mandated services must become fully aware of the culture and context of 106 target populations. Involvement in CWS and its associated challenges are unique circumstances that must be accounted for in therapy, particularly when working with low-income ethnic minority families. For example, therapists introducing parents to complex parenting skills (e.g., the time-out technique), must be aware of the contextual limitations experienced by caregivers, which may significantly limit their ability to practice and master the skill. Thus, delivering interventions without fully considering the contextual and cultural realities of target families may decrease the perceived relevance of PT techniques and alienate clients. It is also crucial for family therapists to inform clinical work according to advocacy principles when working with low-income families exposed to multiple contextual challenges, including CWS involvement. Families serviced by CWS are very likely to need additional support to access multiple resources aimed at helping them reach stability, safety, and wellbeing. Therefore, family therapists must become familiar with relevant supportive services and resources to provide families culturally and contextually relevant therapeutic services. Family therapists aiming to implement PT programs must also inform their practice according to relevant IPV considerations. Clinicians must become familiar with best practices for IPV screening and intervention when delivering parenting programs, as perpetrators may distort PT concepts to control and undermine their partners. Thus, attention to IPV issues when working with families on parenting concerns is critical to ensure the positive impact of PT components and safety of survivors and their children. Finally, it is important to highlight that family therapists are well poised to effectively deliver evidence-based PT interventions to multi-stressed diverse families as a result of their rigorous training in systems and family interventions. For example, transgenerational family therapy approaches are particularly effective when working with families on parenting issues that 107 are linked to transgenerational trauma. Family therapists’ unique clinical training, along with a robust understanding of the cultural and contextual factors that affect target populations are likely to increase the relevance and impact of adapted PT interventions. Conclusion This study offers a relevant contribution to the field, particularly as it refers to issues of cultural adaptation, parent training, and the reduction of mental health disparities in child welfare systems. Current findings provide justification to conduct new lines of investigation focused on determining the best cultural adaptation and service delivery approaches to serve low-income ethnic minority populations in the child welfare system. These efforts have the potential to contribute toward the reduction of child maltreatment by promoting culturally relevant and efficacious preventative services to underserved communities. The reflections by one parent (participant #104) captured the urgency and relevance for expanding this line of inquiry: I participated in the program because the court sent me because I had problems. But this program can help everyone become better parents, better human beings…This program should be for everyone in the community because sometimes parents are going through difficult situations without any support whatsoever. This program would help. 108 APPENDICES 109 APPENDIX A: Figure A.1: Holtrop et al.’s (2014) theory of change in GenerationPMTOR Figure A.1: Holtrop et al.’s (2014) theory of change in GenerationPMTOR 110 APPENDIX B: Table A.1: Culturally adapted evidence based parenting programs for Latinx populations 111 Table A.1 (cont’d) 112 Table A.1 (cont’d) 113 Table A.1 (cont’d) 114 APPENDIX C: PTC-R Parents’ Consent Form (English) Purpose of the Study: We are conducting a research study to learn about your experiences in the parenting program you participated in at the Coalition for Hispanic Family Services. We are interested in learning from you the things that were helpful to you and the things that were not as helpful about this program. We are also interested in understanding how difficult life experiences have influenced your parenting practices and experience in the program. We will use this information to gain better understanding of this parenting program can lead to changes in parenting practices and other relationships. The overall goal of the study is to help improve the parenting program so that it can be more helpful to families. Participation in the Study Includes: You are being asked to participate in one individual interview, which will take approximately 1 hour. This interview will focus on exploring your experiences with the parenting program (PTCR) in which you participated. For example, you will be asked questions about how different aspects of the program were helpful or not helpful to you. You will be also asked to reflect on difficult life experiences you have had throughout your life and how you think those experiences have influenced your parenting, relationships with others, your experience in the parenting program. This interview will be audiotaped to ensure that we accurately document your responses. By consenting to participate in the study, you are consenting to have your responses in the interview be audio-recorded. I agree to allow audiotaping of the interview. Yes No Initials____________ In addition to the interview, you will be asked to complete an informational questionnaire with some general questions about yourself (age, marital status, etc.) and your experience in the parenting program. You will receive $30 as compensation for your time and effort participating in this study. You are being asked to participate in a research study about services you have already received. This study will not provide you with any form of mental health service. If you feel you are in need of mental health treatment, you are encouraged to contact the Coalition’s outpatient mental health services or your local community mental health agency. Privacy and Confidentiality: Your confidentiality will be protected to the maximum extent allowable by law. Confidentiality would only be broken if you report abuse of children, elderly adults, or if you report you are going to harm yourself or someone else. The only people with access to your research data will be Gabriela López Zerón and Dr. Parra Cardona. In addition, the Michigan State University Human Subjects Protection Program may also have access to your data, in the event of an audit. The audio recordings of your interview will be labeled with an ID number and will not be linked 115 in any way to your name or contact information. Only Gabriela López Zerón and Dr. ParraCardona will have access to the list linking your name to your interview and questionnaire. Your contact information will be stored in a locked file cabinet within a locked office and on the researcher’s password protected computer. We will keep all data associated with this research project for three years after the project is closed, during which time it will be stored in a locked file in the principal investigator’s office. The findings of this study will be reported to many people and organizations. People who may hear the findings of this study include students and faculty at Michigan State University, the Administration of Child Services (ACS), and others in the academic community. When the results of this study are presented and published, pseudonyms will be used and any identifying information will be modified or omitted to protect the identity of participants. Your Rights to Participate, Say No, or Withdraw: Participation in this research study is completely voluntary. You may say no to participation or you may change your mind and decide to stop participating at any time with no negative consequences. You may also choose not to answer any question you do not want to answer. You participation will have no effect on your ability to obtain services at the Coalition or any other community mental heath agency. Withdrawing from the study or not answering questions will not prevent you from receiving compensation for participating in the study. Potential Risks and Benefits: There is a risk that you might experience some discomfort while participating in this study. For instance, you might feel uncomfortable reporting demographic information, talking about some of the experiences you had in the parenting program (PTC-R), or discussing difficult experiences you have had throughout your life. Please remember that your confidentiality will be protected and your identity will not be connected to your answers. If you do experience discomfort, you may always choose not to answer a question that makes you uncomfortable, take a break from answering questions, or you may stop participating in the study at any time with no penalty. You may experience benefits from participating in this study. We expect that you may appreciate having the opportunity to talk about your experiences and to provide feedback about what was helpful to you and not helpful about the parenting program (PTC-R). You may also experience some relief in discussing past life experiences and to explain how you perceive those difficult experiences have interfered with your parenting. You might also experience satisfaction and a sense of empowerment from helping improve the parenting program so that it can be more helpful to more families. If you have any concerns or questions about this study, such as specific scientific issues, how to do any part of it, or to report an injury, please contact the researchers: Gabriela López Zerón, M.S. Michigan State University Human Development and & Family Studies 408 Human Ecology Building East Lansing, MI 48824 116 Phone: (517) 898-5665 Email: lopezga@msu.edu J. Ruben Parra Cardona, Ph.D. Michigan State University Human Development and & Family Studies 3D Human Ecology Building East Lansing, MI 48824 Phone: (517) 432-2269 Email: parracar@msu.edu In addition, if you have any questions or concerns about your role and rights as a research participant or would like to obtain information, offer input, or would like to register a complain about this research study, you may contact, anonymously if you wish, Michigan State University Research Protection Program at (517) 355-2180, FAX: (517) 432-4503, email irb@msu.edu, or regular mail at 202 Olds Hall, MSU, East Lansing, MI 48824. Informed Consent: Your signature below indicates your voluntary agreement to participate in this research study. Thank you for your time. Signature: _____________________________________________Date: ____________ You will be given a copy of this form to keep 117 APPENDIX D: PTC-R Parents’ Consent Form (Spanish) Propósito del Estudio: Este es un estudio de investigación para aprender acerca de sus experiencias en el programa de prácticas de crianza en el que usted participó en la agencia Coalition for Hispanic Family Services. Estamos interesados en aprender que fue lo que le ayudó del programa y que cosas no le fueron de mucha ayuda. También estamos interesados en comprender de que forma experiencias difíciles en su vida han influenciado sus prácticas de crianza y participación en este programa. Utilizaremos esta información para comprender a mas profundidad como este programa de practicas de crianza puede producir cambios en las practicas de crianza y en otras relaciones interpersonales de aquellos que lo reciben. El objetivo de este estudio es ayudar a mejorar el programa para que sea de aun mas utilidad para las familias que lo reciben. Su Participación en el Estudio Incluye: Usted participará en una entrevista individual que tomará aproximadamente 1 hora. Esta entrevista estará enfocada en explorar sus experiencias con el programa de practicas de crianza PTC-R en el que usted participó. Por ejemplo, se le harán preguntas acerca de cómo los componentes del programa de fueron, o no le fueron, de ayuda. También se le pedirá que reflexione acerca de experiencias difíciles que usted ha tenido durante la trayectoria de su vida and que nos comente como esas experiencias han influido en sus prácticas de crianza, relaciones con los demás, y su experiencia en este programa. El audio de esta entrevista será grabado para asegurar que estamos documentando su respuestas correctamente. Al decidir participar en este estudio, usted también está dando su consentimiento para que grabemos el audio de esta entrevista. Estoy de acuerdo con que el audio de esta entrevista sea grabado. Si No Iniciales____________ También le pediremos que complete un pequeño cuestionario con algunas preguntas generales (edad, estatus marital, ect.). Usted recibirá $30 como agradecimiento por su tiempo y esfuerzo. El pago será con una tarjeta de regalo o un envio de Western Union. En este estudio se le esta pidiendo que participe en una investigación acerca de los servicios que usted ya recibió. Este estudio no es en ninguna forma un programa terapéutico. Si usted siente que necesita apoyo de servicios de salud mental, le animamos a que contacte a la oficina de salud mental de la agencia Coalition o alguna agencia de salud mental en su comunidad. Privacidad y Confidencialidad: Su confidencialidad será protegida al grado máximo permitido por la ley. Sin embargo, todos los profesionales que trabajan directa o indirectamente con niños deben de reportar todas las veces que ellos tengan conocimiento de situaciones de abuso o negligencia infantil. Abuso infantil se refiere a comportamientos que ponen en peligro el bienestar físico o emocional de un niño/a. Ejemplos de abuso son castigo físicos que dejan marcas de abuso. Un ejemplo de abuso emocional es gritar frases abusivas a un niño/a. Negligencia infantil se refiere a omisiones de 118 actuación para asegurar el bienestar físico o emocional de un niño/a. Por ejemplo, no llevar a un niño a obtener ayuda médica a pesar de claras señales de enfermedad. Además de nuestra obligación de reportar abuso o negligencia infantil, también tenemos la obligación ética a reportar a las autoridades si usted amenaza con hacerse daño o si usted reporta querer hacerle daño a otra persona. Las únicas personas que tendrán acceso a sus datos serán Gabriela López Zerón y el Dr. Jose Ruben Parra Cardona. El programa de Protección de Sujetos Humanos en Investigación de la Michigan State University también tendrá acceso sus datos, en el caso de una auditoría. Las grabaciones del audio de las entrevistas serán marcadas con un número de identificación que no estará ligado a su nombre o información personal. Solamente Gabriela López Zerón y el Dr. Parra-Cardona tendrán acceso a la lista que contendrá los números de identificación asignados a su entrevista y cuestionario de datos demográficos. La información que nos proporcione será guardada bajo llave en una oficina privada en Michigan State University por un período mínimo de tres años después de que cierre el proyecto y la información será accesible al equipo de investigación y de IRB. Los resultados de esta investigación serán reportados públicamente. Algunas de las personas expuestas a estos resultados incluye estudiantes y profesores de Michigan State University, Administration of Child Services (ACS), y otros en la comunidad académica. Cuando los resultados de este estudio sean presentados y publicados, seudónimos serán utilizados y toda información personal será modificada o omitida para proteger la identidad de participantes. Su Derecho a Participar, Decir que No, o Retirarse del Estudio: Su participación en este estudio es completamente voluntaria. Usted puede decidir no participar o retirarse del estudio en cualquier momento sin consecuencias negativas. Usted también puede negarse a responder ciertas preguntas sin consecuencias negativas para usted. Su participación en este estudio no impactará su habilidad de obtener servicios en la agencia Coalition for Hispanic Family Services o cualquier otra agencia comunitaria. El retirarse del estudio o el negarse a contestar preguntas no implica ninguna pena o perdida de beneficios a los que tiene derecho. Riesgos y Beneficios: Usted puede experimentar un malestar ligero como parte de este estudio. Por ejemplo, usted puede experimentar malestar al hablar de algunos datos demográficos, de las experiencias de tuvo en el programa de PTC-R, o al discutir experiencias difíciles que ha tenido en su vida. Por favor recuerde que su confidencialidad será respetada y su identidad no será conectada a sus respuestas. Si usted siente malestar, usted puede decidir no contestar alguna pregunta que le haga sentirse incomodo/a. En caso de experimentar malestar, usted también puede tomarse un descanso o decidir retirarse del estudio sin ningún tipo de penalidad. Finalmente, si usted considera que necesita apoyo adicional, se le entregaran referencias adecuadas para servicios de consejería. Usted puede experimentar beneficios al participar en este estudio. Esperamos que usted va a apreciar la oportunidad de hablar acerca de sus experiencias y de proveer su opinión acerca de que aspectos del programa PTC-R le fueron o no le fueron de ayuda. Usted también puede experimentar alivio al hablar de cómo algunas de sus experiencias han interferido con sus 119 practicas de crianza. Usted también puede sentir satisfacción y un sentido de empoderamiento al dar su opinión de cómo se puede mejorar este programa para que sea de mayor beneficio a mas familias. Si usted tiene dudas o preguntas acerca de este estudio, acerca del proceso científico, como hacer alguna parte del estudio, o quisiera reportar una queja o daño, por favor contacte a: Gabriela López Zerón, M.S. Michigan State University Human Development and & Family Studies 408 Human Ecology Building East Lansing, MI 48824 Phone: (517) 898-5665 Email: lopezga@msu.edu J. Ruben Parra Cardona, Ph.D. Michigan State University Human Development and & Family Studies 3D Human Ecology Building East Lansing, MI 48824 Phone: (517) 432-2269 Email: parracar@msu.edu Si usted tiene preguntas ó preocupaciones respecto a su rol y derechos como participante en esta investigación, ó quisiera obtener información u ofrecer retroalimentación, ó quisiera registrar una queja respecto a este estudio, usted puede contactar, anónimamente si usted lo desea al Programa de Protección de Sujetos Humanos en Investigación al teléfono 517-355-2180, Fax 517-4324503, ó por email a: irb@msu.edu, ó por correo regular al 408 W. Circle Drive, 207 Olds Hall, MSU, East Lansing, MI 48824. Consentimiento Informado: Su firma indica que usted accede de manera voluntaria a participar en este estudio de investigación. Muchas gracias por su tiempo. Firma del padre/madre: __________________________________Fecha: ____________ Se le entregará una copia de este documento 120 APPENDIX E: PTC-R Interventionists’ Consent Form Purpose of the Study: We are conducting a research study to learn about participants’ experiences in the parenting program for biological parents involved in the CWS at the Coalition for Hispanic Family Services. As a certified PTC interventionist, you have been delivering the PTC-R program to biological parents of children placed in foster care at the Coalition. You are being invited to participate in a study documenting the views and opinions of certified PTC interventionist regarding participants’ processes of change and experiences in the program. Participation in the Study Includes: You are being asked to participate in one individual interview, which will take approximately 30-45minutes. Participation in this research project is completely voluntary. You have the right to say no or change your mind and withdraw from the study at anytime. You may also choose to not answer specific questions or to stop participating at anytime. This interview will be audiotaped for accuracy. These audio recordings will be kept in a safe location. Potential Benefits and Risks: The potential benefits for you taking part in this study is that you will receive a $25 gift card for your participating in this interview. The potential risk for you for taking part in this study is that our questions may cause you discomfort. Please remember that you do not have to answer any questions you do not want to, and you can discontinue your participation at any time. Privacy and Confidentiality: Your privacy will be protected to the maximum extent allowable by law. Your interview will be kept in a locked cabinet, separate from any identifying information about you. Your contact information will be stored in a locked file cabinet within a locked office and on the researcher’s password protected computer. The findings of this study will be reported to many people and organizations. People who may hear the findings of this study include students and faculty at Michigan State University, the Administration of Child Services (ACS), and others in the academic community. When the results of this study are presented and published, pseudonyms will be used and any identifying information will be modified or omitted to protect the identity of participants. If you have any concerns or questions about this study, such as specific scientific issues, how to do any part of it, or to report an injury, please contact the researchers: Gabriela López Zerón, M.S. Michigan State University Human Development and & Family Studies 408 Human Ecology Building East Lansing, MI 48824 Phone: (517) 898-5665 121 Email: lopezga3@msu.edu J. Ruben Parra Cardona, Ph.D. Michigan State University Human Development and & Family Studies 3D Human Ecology Building East Lansing, MI 48824 Phone: (517) 432-2269 Email: parracar@msu.edu In addition, if you have any questions or concerns about your role and rights as a research participant or would like to obtain information, offer input, or would like to register a complain about this research study, you may contact, anonymously if you wish, Michigan State University Research Protection Program at (517) 355-2180, FAX: (517) 432-4503, email irb@msu.edu or regular mail at 202 Olds Hall, MSU, East Lansing, MI 48824. Informed Consent: Your signature below indicates your voluntary agreement to participate in this research study. Thank you for your time. Signature: _____________________________________________Date: ____________ You will be given a copy of this form to keep 122 APPENDIX F: PTC-R Parents’ Interview Guide (English) A few months ago, you participated in a parenting program, Parenting through Change for Reunification (PTC-R), at the Coalition as part of the process of your child returning back home from foster care. I am here today because I am interested in learning about this program so we can make it as useful as possible for parents receiving it. In particular, I am interested in your personal experiences in the program. There are no right or wrong answers to my questions. I am looking for your honest opinions and personal experiences. I also want you to know that your name will not be tied to any of the answers that you provide. Please feel free to interrupt, ask questions, or give me your opinion about what I am asking at any point during the interview. General Experience 1. Could you please start by telling me about the experiences you had in the parenting program you participated in? Specifically: • What aspects of the parenting program helped you the most? • What aspects of the parenting program positively impacted your child’s behavior? 2. In what ways your experience in the parenting program helped you change or improve your: • relationship with others? • personal coping/life skills? Content of Intervention Let’s talk about some of the topics discussed in the parenting program. Core Components: 1. One topic covered in the program was skill encouragement, where you provide incentives to your children to help teach them positive behavior. How did learning about this topic help you, or not help you, with your parenting practices? 2. Another topic covered in the program was positive involvement, where you give your children loving attention and spend quality time with them. How did learning about this topic help you, or not help you, with your parenting practices? 3. Another topic covered in the program was limit setting, where you use consequences like time out or work chores to discourage negative behaviors. How did learning about this topic help you, or not help you, with your parenting practices? 4. Another topic covered in the program was problem solving, where you solve disagreements, negotiate rules, and decide on consequences for behavior. How did learning about this topic help you, or not help you, with your parenting practices? 5. Another topic covered in the program was monitoring, where you keep track of where your children are, who they are with, and what they are doing. How did learning about this topic help you, or not help you, with your parenting practices? Supportive Components: 6. One skill you learned was good directions, where you practice giving simple, clear, and specific directions. How did learning about this topic help you, or not help you, with your parenting practices? 123 7. Another skill you learned was about emotional regulation, where you learn ways to stay calm in tense situations. How did learning about this topic help you, or not help you, with your parenting practices? 8. Another skill you learned was about active communication, where you practice active listening and speaking skills. How did learning about this topic help you, or not help you, with your parenting practices? Delivery of Intervention Now I’d like to ask you some questions about the way the parenting program was delivered. 1. How did the delivery of the information you learned help you, or not help you, learn the skills and topics presented? • How did learning through role plays help you, or not help you, with your parenting practices? • How did learning through home practice assignments help you, or not help you, with your parenting practices? 2. Were there any specific ways in which the material was delivered that influenced your participation in a positive way? Negative way? Other Characteristics, Cultural, & Contextual Issues I now have some questions about other issues that might have impacted your parenting practices and your experience in the parenting program. 1. Do you see yourself as a person of color? As an ethnic minority? • How well does the program support your efforts as a person of color/ethnic minority? • When you think about your parenting experiences as a person of color/ ethnic minority and in the world in general, what is missing? Cultural Relevance: 1. How well did the language used in the program reflect your personal verbal style and expressions? 2. How well did the group facilitator understand your culture, values, and traditions? • How did the facilitator (and the fact they were Latinx/bilingual or Black) help you, or maybe did not help you, as you went through this parenting program? Why? 3. How well did the examples and sayings such as “shine the light” used in the program reflect your personal values and traditions? 4. How well did the skills learned in the program, activities, and home practice assignments reflect your culture, values, and traditions? 5. How do you hope that attention to cultural issues would have been increased throughout the intervention? The Impact of Discrimination: Current times are challenging for ethnic minority populations in this country. Some parents have talked to us about how this program has been helpful in some way as they manage issues of discrimination. 6. Does that apply to you? If so, in what ways have you found this program helpful in managing experiences of discrimination? 124 7. How do you think the group facilitators approach to issues of discrimination could be improved? Power in the Co-Parenting Relationship: 8. How in sync with your child’s father (mother) are you in terms of parenting strategies? • Does (s)he support your parenting strategies? • Does (s)he interfere with your parenting strategies? • Is it safe for you to disagree with them on parenting strategies? Final Thoughts: 9. If you could have changed the program based on your needs as ________ (mention identities as explicitly voiced by participants, such as Latinx single mom or African American parent), what would you change? 125 APPENDIX G: PTC-R Parents’ Interview Guide (Spanish) Hace unos meses, usted participó en un programa de practicas de crianza, PTC-R, en la agencia Coalition como parte del proceso de reunificación con su hijo/a. Yo estoy aquí hoy por que estoy interesada en aprender acerca de sus experiencias en el programa para poder asegurarnos que el programa esta siendo los mas útil posible para los padres que lo reciben. En particular, esto interesada en sus experiencias personales en el programa. No hay respuestas correctas o incorrectas a las siguientes preguntas. Yo solo estoy buscando escuchar su opinión honesta y sus experiencias personales. También le recuerdo que su nombre no estará ligado a ninguna de sus respuestas. Por favor siéntase en confianza de interrumpirme, hacerme preguntas, o darme su opinión en cualquier momento durante la entrevista. Experiencia General 1. Podría comenzar por contarme acerca de su experiencia en el programa para padres? • ¿Qué aspectos del programa le fueron de mayor ayuda? • ¿Qué aspectos del programa influenciaron positivamente en el comportamiento de su hjo/a? 2. De que maneras su experiencia en el programa le ayudo cambiar o mejorar sus: • Relaciones con los demás? • Estrategias para enfrentarse a los problemas diarios o estrategias de supervivencia? Contenido de la Intervención Ahora hablemos un poco acerca de los temas discutidos en el programa para padres. Componentes Centrales: 1. Uno de los temas del programa es el de Nuevas Habilidades, en el cual usted provee incentivos a sus hijos para ayudarles a aprender comportamientos positivos. De que forma le ayudó, o no le ayudó, este tema con sus prácticas de crianza? 2. Otro de los temas del programa es el de Involucramiento Positivo, en el cual usted le da atención y cariño a sus hijos. De que forma le ayudó, o no le ayudó, este tema con sus prácticas de crianza? 3. Otro de los temas del programa es el de Límites, en el cual usted utiliza consecuencias como el tiempo fuera o los quehaceres especiales para limitar los comportamientos negativos. De que forma le ayudó, o no le ayudó, este tema con sus prácticas de crianza? 4. Otro de los temas del programa es el de Solución de Problemas, en el cual se negocia reglas y a decidir consecuencias a comportamientos negativos. De que forma le ayudó, o no le ayudó, este tema con sus prácticas de crianza? 5. Otro de los temas del programa es el de Monitoreo, en el cual usted se mantiene al tanto de donde están sus hijos, con quien están, y que están haciendo. De que forma le ayudó, o no le ayudó, este tema con sus prácticas de crianza? 126 Componentes de Apoyo: 6. Uno de los temas que aprendió es el de Buenas Direcciones, en el que usted practica el dar direcciones que son simples, claras y especificas. De que forma le ayudó, o no le ayudó, este tema con sus prácticas de crianza? 7. Otro de los temas que aprendió es el de Regulación Emocional, en el que aprendió a mantenerse en calma en situaciones estresantes. De que forma le ayudó, o no le ayudó, este tema con sus prácticas de crianza? 8. Otro de los temas es de Comunicación Activa, en el que usted practica el hablar y escuchar activamente. De que forma le ayudó, o no le ayudó, este tema con sus prácticas de crianza? Presentación de Intervención Ahora me gustaría hacerle algunas preguntas acerca de la forma en el que el programa fue difundido. 1. De que forma le ayudó, o no le ayudó, la forma en que los temas fueron presentados a aprender las habilidades e información del programa? • ¿De que forma de ayudó, o no le ayudó aprender a través de los juegos de roles? • ¿De que forma de ayudó, o no le ayudó aprender a través de las practicas para la casa? 2. Hubieron algunas maneras especificas en las que el material fue presentado que influyeron en usted de manera positiva? De manera negativa? Otras Características, Temas Culturales y Contextuales Ahora tengo algunas preguntas acerca de otras cuestiones que pudieron haber impactado sus prácticas de crianza y su experiencia en el programa. 1. ¿Usted se identifica como Latin@/ Hispan@? 2. ¿Qué tanto le ayudo a esta intervención a sus esfuerzos de crianza como papa/mama Latin@/ Hispan@? 3. Que esta faltando en esta intervención? Relevancia Cultural: 1. ¿Qué tanto refleja el lenguaje utilizado en el programa su propio estilo de hablar y expresiones de preferencia? 2. ¿Qué tan bien entiende el facilitador su cultura, valores, y tradiciones? • ¿De forma le fue de ayuda el hecho que el facilitador fuese Latina/bilingüe al aprender de este programa? 3. ¿Qué tan bien reflejan los ejemplos y dichos utilizados en el programa sus valores personales y tradiciones? 4. ¿Qué tan bien reflejan las habilidades aprendidas en el grupo, actividades, y practicas para la casa sus valores personales y tradiciones? 5. ¿De que forma le gustaría que se incremente la atención a temas culturales durante el programa? El Impacto de la Discriminación: La situación actual es difícil para muchos Latinos en este país. Algunos padres nos han reportado que este programa les es de ayuda para manejar mejor cuestiones de discriminación. 6. ¿Se identifica con eso? Si es así, ¿de que forma le ayudó este programa para manejar situaciones de discriminación? 127 7. ¿De que forma piensa que se podría mejorar el manejo de temas de discriminación? El Poder en la Relación de Crianza Compartida: 8. ¿Qué tan de acuerdo está usted con el padre (la madre) de su hijo/a en cuanto a temas de crianza? • Apoya sus estrategias de crianza? • Interfiere con sus estrategias de crianza? • Se siente usted cómodo/a y a salvo como para mencionar cuando usted no está de acuerdo con las practicas de crianza? Última Pregunta: 9. Si usted pudiera cambiar en programa basado en sus experiencias como _______________(mencione la forma en que la persona se identificó, como mamá soltera de bajos recursos), ¿qué cambios haría? 128 APPENDIX H: PTC-R Interventionists’ Interview Guide I am interested in learning about your views regarding parents’ process of change and their experiences in the program. There are no right or wrong answers to my questions. I am looking for your honest opinions, views and personal experiences. Your responses will not be tied to your identity. Please feel free to ask any clarifying questions at any point during the interview. I truly appreciate the time you are taking to talk with me. 1. What is your job description and how long have you been working in this field? 2. How long have you been a PTC interventionist? Content of Intervention Let’s talk about some of the topics discussed in the parenting program. 1. What are some of topics/sessions that stand out as the most significant for parents? 2. What do you think are some aspects that helped parents change of improve their: • parenting practices? • relationships with others? • personal coping/life skills? Core Components: 3. One topic covered in the program was skill encouragement. How do you think learning about this topic helped parents with their parenting practices? 4. Another topic covered in the program was positive involvement. How do you think learning about this topic helped parents with their parenting practices? 5. Another topic covered in the program was limit setting. How do you think learning about this topic helped parents with their parenting practices? 6. Another topic covered in the program was problem solving. How do you think learning about this topic helped parents with their parenting practices? 7. Another topic covered in the program was monitoring. How do you think learning about this topic helped parents with their parenting practices? Supportive Components: 8. Another skill taught in the program is good directions. How do you think learning about this topic helped parents with their parenting practices? 9. Another skill taught in the program is emotional regulation. How do you think learning about this topic helped parents with their parenting practices? 10. Another skill taught in the program is active communication. How do you think learning about this topic helped parents with their parenting practices? Other Content: 11. Were there any topics in particular that you believe influenced participants more than others? 12. Were there any topics in particular that you believe made participants’ frustrated or reluctant to make changes? 129 Delivery of Intervention Now I’d like to ask you some questions about the way the parenting program was delivered and your opinion regarding how much they helped parents’ process of change Specific Methods: 1. How did learning through role plays help parents make changes in their parenting practices? 2. How did learning through home practice assignments help parents make changes in their parenting practices? Other Characteristics, Cultural, & Contextual Issues: Cultural Relevance: 1. How much attention did you place on parents’ cultural issues and values throughout the parenting program? 2. How did your relationship with the parents help them as they went through this parenting program? 3. Do you think the language used in the program fits with the NYC experience? • To what extent did you tailor the language to reflect parents’ verbal styles and expressions? 4. Do you think the examples, “raps”, and metaphors used in the program fits with the NYC experience? • To what extent did you tailor the examples, “raps”, and metaphors to reflect parents’ culture, values and traditions? 5. Do you think the content of the program fits with the NYC experience? • To what extent did you tailor the content of the program to reflect parents’ culture, values, and traditions? 6. Do you think the activities (i.e., role plays) and/or home practice assignments used in the program fits with the NYC experience? • To what extent did you tailor the activities and/or home practice assignments to reflect parents’ culture, values and traditions? 7. Would you make changes to the sequencing in which the components of the intervention are delivered? If so, what changes? The Impact of Discrimination: 8. In what ways did issues of discrimination come up in the parenting program? • How did you manage and address those issues? Power in the Co-Parenting Relationship: 9. How are reports of domestic violence generally handled within the Coalition? 10. There are some cases in which there is not any physical violence, but men are coercive and domineering towards their female partners. How do you address and manage those instances? Final Thoughts: 11. If you could make three concrete changes to the intervention, what would those be? 12. What has it been like for you to facilitate this parenting program for low-income and ethnic minority parents who have had their children placed in foster care? • What are some of the challenges you have experienced as a facilitator? • What are some of the successes you have experienced as a facilitator? 130 APPENDIX I: Study Demographics Form (English) Participant #: _______________ Date: _______________ Directions: Please fill in the blank or circle the response that best describes you. 1- How old are you? _____________________________________ 3- What is your race? (Circle all that apply) (1) American Indian/Alaskan Native (2) Asian (3) Black, African American (4) Native Hawaiian/Pacific Islander (5) White 4- What is your ethnicity? ____________________ 5- How many children do you have? _____________ 5- What are your children’s ages? __________________________________ 6- What is the highest grade in school that you completed? ________________________ 7- What is your relationship status? (1) Married (2) Divorced (3) Separated (4) Widowed (5) (6) (7) Living together Partnered but not living together Single 8- Are you currently working? (1) Yes, full time employment, in my interest area (2) Yes, full time employment, not in my interest area (3) Yes, part time employment, in one position (4) Yes, part time employment, in multiple positions (5) No, I am currently unemployed (6) Other, please specify: _____________________________________ 9- Currently, what is your family’s approximate annual income? (1) Less than $10,000 per year (2) $10,000- $20,000 per year (3) $20,000 – $30,000 per year (4) $30,000 - $40,000 per year (5) $40,000 - $50,000 per year (6) More than $50,000 per year 131 APPENDIX J: Study Demographics Form (Spanish) Participante #: _______________ Fecha: _______________ Instrucciones: Favor llene el espacio o circule la respuesta que lo/a describa mejor. 1- ¿Cuántos años tiene? _____________________________________ 2- ¿Cuál es su identidad étnica? __________________________________ 3- ¿Cuál es su raza? (Circule todas las que aplican) (1) Indio Americana/ Nativa de Alaska (2) Asiática/o (3) Negra/o o Afro Americana/o (4) Nativo de Hawái u otra Isla Pacifica (5) Blanca 4- ¿Cuántos hijos tiene? _____________ 5- ¿Qué edades tienen sus hijos? __________________________________ 6- ¿Cuál es el grado de educación mas alto que usted completó? ______________________ 7- ¿Cuál es el estatus de su relación de pareja? 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