Journal of Pediatric Psychology, Vol. 27, No. 4, 2002, pp. 339-350
© 2002 Society of Pediatric Psychology
Cultural Issues in the Treatment of Young African American Children Diagnosed With Disruptive Behavior Disorders
West Virginia University
All correspondence should be sent to Cheryl B. McNeil, Department of Psychology, West Virginia University, P.O. Box 6040, Morgantown, West Virginia 26506. E-Mail: cmcneil{at}wvu.edu .
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Abstract |
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 Top Abstract IntroductionDisruptive Child Behavior...Correlates of Disruptive Child...African American Children and...Correlates of Disruptive Child...Differences Between African...ParentingTreatment IssuesFuture DirectionsReferences |
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Objective: To discuss issues relevant to treating young African American children with disruptive behavior disorders.
Method: We treat behavior disorders, correlates of behavior disorders, and special differences between African American and Caucasian children that could lead to or explain behavior problems.
Discussion: The majority of the information on young children diagnosed with disruptive behavior disorders has been obtained primarily from Caucasian children and families. Unfortunately, this reliance on Caucasian data neglects the unique needs of minorities and may lessen the quality of the services that they receive. Omission of ethnic concerns becomes even more salient with the increasing ethnic diversity among children and families in the United States.
Conclusions: We suggest future research and clinical directions that will ultimately assist clinicians to provide high-quality mental health services to African American children.
Key words: African American children; race; cultural issues; disruptive behavior disorders; parent training.
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Introduction |
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TopAbstractIntroductionDisruptive Child Behavior...Correlates of Disruptive Child...African American Children and...Correlates of Disruptive Child...Differences Between African...ParentingTreatment IssuesFuture DirectionsReferences |
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Recent information regarding cultural issues in mental health suggests that studying the effects of race on assessment and treatment is crucial to reduce the misdiagnosis of minority clients and to improve the quality of their treatment (e.g., Casimir & Morrison, 1993
; Forehand & Kotchick,
1996; Worthington,
1992). Traditionally, psychology has not been sensitive to
cultural issues in several areas. For example, most assessment instruments and
treatment protocols have been normed on primarily Caucasian populations
(Casimir & Morrison,
1993). Thus, normal, culturally bound behaviors may be confused
with psychopathology (Westermeyer,
1987). Also, clinicians who lack training regarding different
cultural groups bring biases that may hinder treatment effectiveness
(Neal-Barnett, 1996). In fact,
federal studies have examined the effects on diagnosis and treatment of a
Eurocentric therapy focus on minority clients
(Casimir & Morrison,
1993). They have suggested that clients' social and cultural
backgrounds be evaluated, instead of a generic norm
(Casimir & Morrison,
1993). Finally, research has shown an association between race and
diagnosis (Adebimpe, 1981).
This correlation is often evidence of a more fundamental problem: patient
misdiagnosis. According to Worthington, misdiagnosis is common in minority
populations such as African Americans.
These factors contribute to a Eurocentric mentality in psychology that
neglects the needs of minorities and lessens the quality of services they
receive. This omission of cultural concerns is significant because minority
groups increasingly represent a greater proportion of the population of the
United States (U.S. Bureau of the Census,
1994). Fortunately, the Eurocentric approach to assessment and
diagnosis in mental health is beginning to change. Phrases such as
"ethnic pluralism" and "multiculturalism" are common
in social sciences literature, demonstrating an emerging sensitivity to
cultural issues. Additionally, research is emerging on the assessment and
treatment of minority clients (Casimir
& Morrison, 1993), but this research has primarily focused on
adults.
In child clinical psychology, a number of theoretical models have been
emerging that specifically address the importance of cultural/ethnic
considerations. Examples of these integrative models include the behavioral
systems model (e.g., Mash,
1998), multisystemic therapy (e.g.,
Randall & Henggeler,
1999), and the developmental psychopathology/psychotherapy
perspective (e.g., Toth & Cicchetti,
1999). As Toth and Cicchetti explain, "We currently know
that sensitivity to varied developmental trajectories as well as to diverse
parenting practices evident in minority families must be incorporated into our
interventions if treatment is to be appropriate and effective" (p. 24).
Unfortunately, scientific investigations have lagged behind conceptual
understanding, such that data regarding cultural issues in child clinical
psychology, specifically children exhibiting disruptive behaviors, are sparse.
We present an overview of disruptive child behavior problems, discuss the
correlates of disruptive child behavior problems, examine differences between
African American and Caucasian children diagnosed with disruptive behavior
disorders, and offer suggestions for future research and clinical
directions.
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Disruptive Child Behavior Problems |
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A large body of empirical work highlights the importance of studying young children diagnosed with disruptive behavior disorders. Disruptive behavior disorders account for the majority of referrals to mental health clinics (Wells & Forehand, 1985
)
and therefore are a primary concern of clinicians. These disorders include
oppositional defiant disorder, attention deficit hyperactivity disorder, and
conduct disorder. Children meeting the criteria for these disorders exhibit
such maladaptive behaviors as developmentally inappropriate rates of
non-compliance, activity, and aggression
(American Psychiatric Association,
1994). In the majority of these children, problem behaviors do not
spontaneously improve without intervention (e.g.,
McNeil, Capage, Bahl, & Blanc,
1999; Peed, Roberts, &
Forehand, 1977;
Webster-Stratton, Kolpacolf, &
Hollinsworth, 1988). Frequently the behavior problems worsen and
lead to mental health problems in adolescence and adulthood
(Achenbach & Edelbrock,
1981).
In addition to long-term concerns, disruptive behaviors affect several
facets of the young child's life in the short term. Among them are
disturbances in family functioning such as negative parent-child interactions
(Campbell, 1990) and increased
parental stress (Weinberg &
Richardson, 1981). Child functioning in educational settings is
also influenced by disruptive behavior problems. For example, Weiss and
Hechtman (1986) found that
hyperactive children repeated more grades, displayed lower self-esteem, and
eventually obtained fewer years of formal education. Children with disruptive
behavior disorders in elementary and junior high school had lower reading and
math achievement than their peers (Schultz
& Switzky, 1993). Additionally, a relationship exists between
disruptive behaviors and negative peer relations
(Campbell, 1990).
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Correlates of Disruptive Child Behavior Problems |
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Several factors have been identified as relating to the diagnosis of disruptive behavior disorders in children. These include socioeconomic status (SES), parental stress, and family constellation.
Socioeconomic Status
SES affects the cognitive and behavioral development of children
(Duncan, 1994;
Farrington, 1986;
Stone, 1981). Additionally, a
strong correlation has been found between income and poverty and the cognitive
development and behavior of children
(Duncan, 1994). Some studies
have found that children from low-income families have more behavioral and
mental health problems (Davis &
Proctor, 1989; Gortmaker,
Walker, Weitzman, & Sobol, 1990;
Lurie, 1974;
Murphy & Jellenick, 1988;
Swanson, Holzer, Canavan, & Adams,
1989; Touliatos &
Lindholm, 1981). Furthermore, research suggests that clients with
low incomes receive more serious psychological diagnoses (e.g., conduct
disorder; Proctor, Vosler, & Murty,
1992). However, the primary effect of SES on child development can
be difficult to determine because of the strong interaction between SES and
race (Kessler & Neighbors,
1986).
In addition to the association between SES and child behavior problems, a
relationship exists between SES and parenting behaviors. This relationship
ultimately affects the behavior of children negatively. According to McLoyd
(1990), in comparison with
mothers of higher SES, mothers living in poverty are less supportive of their
children and are more likely to use power-assertive techniques when
disciplining their children. Additionally, mothers from a low SES background
place higher value on obedience and are more likely to use physical punishment
to manage their children (McLoyd &
Wilson, 1991). Finally, mothers in low SES homes use commands more
frequently without explaining them, are less likely to ask the child what he
or she wants, and are less likely to give verbal praise to the child for good
behavior (McLoyd, 1990). Harsh
mothering practices have been linked to high rates of internalizing and
externalizing behavior problems (e.g., unhappiness, anxiety, dependence, and
disruptive behavior disorders) exhibited by children
(McLeod & Shanahan, 1993)
and thus may help to explain why many children living in poverty are at risk
for psychological dysfunction.
Finally, SES may also affect the results of clinical measures. One study
found that a sample of non-clinical urban children from low-income families in
the United States scored significantly higher on all subscale scores and on
the total score of the 1983 edition of the Child Behavior Checklist (CBCL;
Radaal, Milgrom, Cauce, & Mancl,
1994). The proportion of children scoring in the
clinical/borderline range was also higher for the sample than for the norm.
This supports previous findings that poverty is a "risk factor"
for child behavior problems. In the normative sample, children of low SES are
under-represented. Therefore, the validity of the CBCL norms has been
questioned. Radaal et al. concluded that SES differences between the sample
and the CBCL norms most likely accounted for score differences and that,
although no studies exist comparing 1991 CBCL norms, the the results likely
would be roughly the same.
Parental Stress
Parental stress also is related to disruptive child behavior problems.
Maternal stress is correlated with such disruptive behaviors as high levels of
negative behavior in hyperactive children
(Mash & Johnston, 1983)
and children diagnosed with oppositional defiant disorder
(Ross, Blanc, McNeil, Eyberg, &
Hembree-Kigin, 1998). In addition, parental stress is related to
the use of various parenting strategies. Stressed parents are less able to
focus on their children (Abidin,
1992). Longfellow, Zelkowitz, and Saunders
(1982) found that stressed and
depressed mothers were more likely to be hostile and dominating and less
responsive to their children's basic needs. Research suggests that these
negative parenting behaviors tend to intensify child disruptive behavior
(Mash & Johnston,
1990).
Furthermore, maternal locus of control is related to stress. Mothers who
have external locus of control perceive that external factors are causing
their child's behavior problems. Consequently, an external locus of control
can serve a stress-buffering function
(Goodban, 1985) and thereby
decrease parental stress because mothers blame factors outside themselves,
such as poverty and child temperament, for child behavior problems
(Schaefer, Edgerton, & Hunter,
1984). Similarly, mothers with internal locus of control likely
experience increased stress levels because they blame themselves for their
child's behavior problems.
Parental stress also is associated with treatment duration. For example,
families experiencing significant levels of stress are more likely to drop out
of treatment after the intake session, especially if the session is extensive
in time and the assessments do not appear to be related to their current
situation (Hembree-Kigin & McNeil,
1995; McNeil & Herschell,
1998). Furthermore, several studies have found that parental
stress is one of many factors (e.g., child's antisocial behavior, parenting
styles) affecting treatment dropout (e.g.,
Kazdin, 1990;
Kazdin & Mazurick, 1994;
Kazdin, Stolar, & Marciano,
1995).
Family Constellation
Another factor related to child behavior problems is family constellation.
Research has shown that a relationship exists between single-parent homes and
child psychological dysfunction. For example, children in single-parent homes
have more behavior problems (Rutter &
Garmezy, 1983). Additionally, a relation has been found between
psychological distress and single motherhood
(Belle, 1984;
McAdoo, 1986;
Pearlin & Johnson, 1977).
Single mothers are more vulnerable to anxiety, depression, and health
problems. If they are poor and live alone with their children, this risk
increases (Guttentag, Salasim, &
Belle, 1980; McLoyd,
1990). The combination of these factors affects parenting styles.
For instance, one study found that single mothers having greater economic
difficulty hit and scolded their children with greater frequency than mothers
reporting more economic resources (McLoyd
& Wilson, 1991). These harsh parenting styles have been linked
to psychological dysfunction in children
(McLeod & Shanahan,
1993).
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African American Children and Disruptive Behavior Problems |
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Race has not been studied extensively in the area of child mental health (Proctor et al., 1992
).
However, the available research suggests that the experiences of minority
children differ from those of Caucasian children. For example, Canino and
Spurlock (1994) report that
adult expectancies for such child behaviors as submissiveness, dependence,
language acquisition, and motor skills differ from culture to culture. Also,
developmental norms vary for different ethnic groups and are affected by SES
and a family's level of acculturation
(Canino & Spurlock, 1994).
Furthermore, ethnicity affects children's presentation of symptoms, their type
of defenses, and how they deal with anger, fear, depression, and anxiety
(Gibbs & Huang, 1989).
Thus, understanding the development of African American children is important
when exploring issues of assessment and treatment for African American
children diagnosed with disruptive behavior disorders. |
Correlates of Disruptive Child Behavior Problems for African Americans |
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The factors that relate to the diagnosis of disruptive child behavior in Caucasian children are even more salient for African American children, placing them at greater risk for psychological dysfunction. These factors are SES, parental stress, and family constellation.
Socioeconomic Status
African American children are more likely than Caucasian children to live
in low-income homes (Edelman,
1985,
1987;
Glick, 1988;
Laosa, 1988;
Slaughter, 1988;
Wilson & Tolson, 1988).
Statistics show that in the general population one in five children under the
age of 18 live below the federal poverty level, whereas almost half of all
African American children live in poverty
(Patterson, Kupersmidt, & Vaden,
1990). The increased incidence of poverty among African American
children has placed them at a greater risk of developing psychological
problems (Gibbs, 1989;
Myers & King, 1983),
especially at school. SES is a more significant predictor of academic success
for African American children than Caucasian children
(Patterson et al., 1990).
Because of the strong relationship between race and poverty
(Sims, 1986), it is difficult
to determine the effects of each variable separately and its impact on mental
health. It can also be difficult to determine the effects of poverty versus
race on the prevalence and cause of mental illness
(Casimir & Morrison,
1993). For instance, a study conducted by Kessler and Neighbors
(1986), based on an analysis
of eight surveys completed by over 22,000 Caucasian and African American
participants, found that race differences in mental distress were greater in
participants with lower incomes than in those with higher incomes.
Furthermore, the authors concluded that when SES is a controlled factor, the
effect of race on psychological distress is decreased but not eliminated.
Finally, socioeconomic disadvantage that is more typically experienced by
African American families than Caucasian families has been linked to the
course of treatment. For example, Armbruster and Schwab-Stone
(1994) found that minority,
single parent, and Medicaid status were linked to dropout at therapy intake
and assessment phases of treatment. Additionally, Kazdin et al.
(1995) found that African
American families dropped out of treatment earlier and with greater frequency
than Caucasian families. Socioeconomic disadvantage was found to be a key
factor related to dropout point for families of both races. However, African
American families were more likely to drop out of treatment despite SES
(Kazdin et al., 1995).
Parental Stress
Unique aspects of parenting stress must be examined when discussing
disruptive behavior problems in African American children. African American
parents experience increased levels of parental stress as compared to their
Caucasian counterparts. Two situations have led to this increase. First, an
inverse relationship exists between SES and parental stress
(Belle, 1984;
McLoyd & Wilson, 1991).
African American families are more likely than Caucasian families to live in
homes headed by single mothers experiencing low SES
(Belle, 1984;
McLoyd, 1990;
Sims, 1986); thus, African
American parents are more likely to experience parental stress. Additionally,
parenting stress has been linked to highly stressful living environments
(e.g., insufficient resources for basic living necessities, dependence on the
extended family for assistance with child care;
Barbarin, 1993) that are more
typical for African American families than for Caucasian families
(Jones & Herndon, 1992).
The elevated level of stress experienced by these African American parents is
of primary consideration because it has a negative impact on parenting
techniques (Abidin, 1992;
Longfellow et al., 1982) and
may actually intensify child problem behavior
(Mash & Johnston,
1990).
Family Constellation
Finally, it is necessary to consider family constellation when exploring
disruptive behavior problems in African American children because they are
more likely than Caucasian children to live in single-parent, mother-headed
homes (Edelman, 1985,
1987;
Glick, 1988;
Laosa, 1988;
Slaughter, 1988;
Wilson & Tolson, 1988). In
1993, 58.3% of African American children lived in single-parent, mother-headed
homes compared to 17.8% of Caucasian children
(U.S. Bureau of the Census,
1994). However, low income is a better predictor of behavior
problems in children than family constellation. For example, at school,
African American children from low-income families have been diagnosed more
frequently with behavior problems than Caucasian children regardless of family
constellation (Patterson et al.,
1990). It is difficult to explore the effects of income and family
constellation on child development because of the strong relationship between
the factors (Sims, 1986).
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Differences Between African American and Caucasian Children |
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TopAbstractIntroductionDisruptive Child Behavior...Correlates of Disruptive Child...African American Children and...Correlates of Disruptive Child...Differences Between African...ParentingTreatment IssuesFuture DirectionsReferences |
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The socialization and needs of African American children are unique in many ways. Not only must African American children struggle to mature into healthy adults as Caucasian children do but they also are challenged to mature in an environment in which they are a racial minority. Thus, the experiences that shape their behavior are different from those of Caucasian children. When examining the socialization and needs of African American children diagnosed with disruptive behavior disorders, one must consider five specific areas: development, assessment, diagnosis, parenting, and treatment. This information highlights some important differences between African American and Caucasian families. Consideration of this information is important to determine whether standard assessments and treatment programs (e.g., behavioral parent-training programs) for children diagnosed with disruptive behavior disorders are appropriate to treat African American children.
Development
It is important for clinicians to consider the unique development of
African American children because a child's background affects behavior.
However, there is disagreement in the literature regarding the qualities and
characteristics of African American families (e.g., role of the father). Most
of this information is not based on empirical research. However, this
literature does provide clinicians with information about African American
families. The most important influence in the development of children is the
family (Grecas, 1981), through
which socialization occurs by reinforcement and modeling
(Sanders Thompson, 1994).
However, inconsistencies emerge in the literature concerning the qualities and
characteristics of African American families (e.g., amount of parental
involvement in the their children's lives). Hurd, Moore, and Rogers
(1995) made the following
general conclusions in their study of African American families from a variety
of economic backgrounds: (1) African American parents are substantially
involved in their children's lives, (2) African American parents receive a lot
of support from caregivers outside the immediate family (e.g., grandmothers,
grandfathers, aunts, uncles, friends), (3) African American children have a
significant amount of male involvement in their lives with fathers being the
most common male role models, and (4) African American parents place an
emphasis on communicating values and teaching acceptable behaviors to their
children. Another major goal in the socialization process of African American
children is the formation of a positive identification toward one's racial
group (Harrison, Wilson, Pine, Chan, &
Buriel, 1990). In fact, racial pride is a foundation on which
African American parents raise their children
(Peters, 1981). For African
American children, racial socialization may be a tool to help them deal with
their social environment (Sanders
Thompson, 1994).
Some researchers interpret the data regarding African American family
characteristics differently. These researchers point to negative factors that
can contribute to psychological problems in African American children. For
instance, 43% of African American children live in female-headed,
single-parent homes (U.S. Bureau of the
Census, 1994). Many of these homes are unstable and have limited
economic resources (Barbarin,
1993). All of these factors threaten the emotional development of
African American children and place them at risk for psychological dysfunction
(e.g., Swanson et al., 1989).
Furthermore, African American children are more likely than Caucasian children
to live in unsafe and unsupportive environments
(Barbarin, 1993). The problems
in the environments of a significant proportion of African American children
include (1) inadequate resources to provide basic living necessities, (2) the
feeling of hopelessness about changing the family's current situation, (3)
unstable or no parental involvement in the lives of preadolescents and
adolescents, (4) an unstable place of residence, (5) lack of supervision when
children are not in school, and (6) pressure on the extended family to help
parents (Barbarin, 1993).
The unique culture of African Americans affects how their children develop
emotionally as well as the behavior and learning strategies these children
employ in academic settings. The traditional academic setting is often not
effective for African American children. African American children are labeled
more frequently as "hyperactive" or "mentally
retarded" than other races
(Hale-Benson, 1986). Experts
who study and write about African American development have theorized about
race differences in academic settings. For example, Morgan
(1976) suggested that African
American parents from low SES may place more importance on teaching their
children how to survive (e.g., coping with a racist society) than on teaching
quiet behaviors. These different values may be less acceptable to the
traditional school system, leading to greater punishment and labeling of
African American children (Morgan,
1976).
Standardized Assessments
Several standardized assessments are generally administered when diagnosing
disruptive child behavior problems. These measures include the CBCL, the
Eyberg Child Behavior Inventory (ECBI), and the Parenting Stress Index (PSI).
The test samples for each of these samples were predominantly Caucasian. In
the 1991 normative sample for the CBCL, 74% of the population was white, 16%
was African American, and 10% was classified as other
(Radaal et al., 1994). In the
1980 normative sample for the ECBI, the majority of children came from lower
and middle income Caucasian families having two children
(Robinson, Eyberg, & Ross,
1980). The PSI normative sample consisted of the following
distribution: 76% of the population was Caucasian, 11% was African American,
10% was Hispanic, and 2% was Asian (Abidin,
1995). The distributions of these normative samples are usually
designed to correspond with census distribution. However, these norms may be
problematic for minority populations, and the lack of African American
children in these test samples demonstrates the need to further study African
American children diagnosed with disruptive behavior disorders. It would be
helpful, for example, to have African American norms on these measures for
comparison purposes. African American norms might help with the problem of
overdiagnosing certain disorders because of the child's race. Yet, if such
studies showed that African American children have higher levels of disruptive
behavior that are normative and accepted within that cultural group, there
still would have to be larger-system changes to encourage teachers and others
to accept these differences.
Diagnosis
Of the studies that have focused on child diagnosis, many have not
precisely described their subject population, and others have not addressed
race in the diagnosis (Proctor et al.,
1992). In addition, external variables also are related to the
diagnosis of African American children. For example, income level and gender
were better overall predictors of behavior problems than ethnicity or family
constellation (Patterson et al.,
1990). Furthermore, the most important factor in observable
differences between African American and Caucasian children is poverty
(Edelman, 1987;
Patterson et al., 1990). In
exploring child diagnosis, minority children have been found to be identified
with higher rates of psychosocial dysfunction
(Murphy & Jellinek, 1988),
especially based on pediatrician reports
(Goldberg, Roghman, McInery, & Burke,
1984). In a study of the DSM-III, Caucasian children were more
likely to be diagnosed with oppositional defiant disorder, and African
American children were more likely to be diagnosed with conduct disorder
(Proctor et al., 1992).
Minorities, boys, and low-income children were more likely to be diagnosed
with persistent, serious problems relating to neurological, attention, and
conduct functioning (Proctor et al.,
1992). In contrast, certain symptoms exhibited by African American
children, which would be viewed as problematic in Caucasian children, are
sometimes overlooked by professionals
(Lewis, Balla, & Shanok,
1979). According to Lewis et al., examples of these neglected
symptoms include hallucinations, paranoid thought patterns, and bizarre
behaviors (e.g., swallowing sharp objects). Professionals in the study
interpreted these symptoms to be culturally acceptable or manipulatory
behaviors in African American juvenile delinquents.
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Parenting |
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Research on parenting suggests that a relationship exists between parenting values and culture (e.g., Ogbu, 1981
). Cultural influence on parenting behavior is seen in the
African American community. For example, African American parents are more
likely to utilize physical punishment and emotional withdrawal than other
ethnic groups because of the high value that they place on obedience
(Peters, 1981). Additionally,
in African cultures, the community (e.g., extended family members, church
members, neighbors) often works in conjunction with parents to raise children
(Franklin & Boyd-Franklin,
1985). Hurd et al.
(1995) identified other
qualities that distinguish African American parents: (1) African American
parents teach their children special skills to cope with their unique
environment (e.g., racism) and hold different values than Caucasian parents;
(2) parents of African American children report that teaching self-reliance,
through such means as problem solving, resolution of conflict, and
self-defense, is a necessity that society requires of their children; (3)
African American parents teach pain and coping skills to their children and
hold unique parenting philosophies; and (4) parents of African American
children report that their children should be prepared to deal with life's
pain and disappointments rather than be protected from them. Because African
American parents value different parenting strategies than Caucasian parents,
typical parenting programs designed for Caucasian families may not address
their unique needs.
For example, contrary to what might be expected based on Caucasian
parenting values, research suggests that an African American parenting style
that is more restrictive and authoritarian leads to better outcomes in
children from high-risk environments
(Baldwin, Baldwin, & Cole,
1990). It is critical that assumptions about effective parenting
based on Caucasian values be tested empirically within the context of various
cultures, developmental stages, and environments
(Toth & Cicchetti,
1999).
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Treatment Issues |
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The literature on the response of African American families to treatment for child disruptive behavior is limited and inconclusive. Some research has linked race to treatment dropout. For example, minority status has been found to be related to treatment dropout for adult psychotherapy outpatients (ages 29-68; Greenspan & Kulish, 1985
). Additionally, race has been found to be related to
premature treatment termination for families receiving treatment at a child
guidance clinic (Armbruster &
Schwab-Stone, 1994; Swingle,
Calsyn, & Worland, 1986) and for families of children who
exhibit antisocial behavior (Kazdin,
Mazurick, & Bass, 1993;
Kazdin et al., 1995). Yet a
recent study of 56 children receiving parent-child interaction therapy (half
of whom were African American) found no differences between the groups on
measures of treatment outcome (Capage,
Bennett, & McNeil, 2001). The authors suggested that their
study may have produced different findings because the African American and
Caucasian groups were matched on the basis of SES. Alternatively, there may be
differences in the cultural sensitivity of different treatments for disruptive
behavior problems. For example, Webster-Stratton's
(1996) videotape-based parent
intervention program has had a strong track record of success with high-risk
children from a variety of cultural backgrounds. Hanf-model programs like
parent-child interaction therapy and the videotape modeling approach might be
more effective with African American families because of the inclusion of a
specific discipline program for increasing child compliance. Unfortunately, it
is too soon to interpret these findings. At this point, the literature is too
sparse to form conclusions about the cultural applicability of various
treatments for disruptive behavior problems.
When greater treatment dropout for African American families has been
found, authors have speculated about possible reasons why these families might
be less likely to complete therapy. One factor is the relative value that
minority clients place on therapy. For example, in the late 1960s and early
1970s, there was a movement to use behavioral therapies in African American
communities (Neal-Barnett,
1996). However, many African American families stated that these
programs did not address their needs and values. For example, the behaviors
targeted in these programs (e.g., low activity levels, limited verbalizations)
were contradictory to the African American value system
(Neal-Barnett, 1996). This may
have alienated many African American parents from traditional behavioral
parent-training therapies. Another factor that could increase dropout rates
for African American families is race of the therapist. It is possible that
less dropout would be evident when clients and therapists are matched for race
(e.g., Atkinson et al., 1996).
Unfortunately, research in this area is lacking, preventing conclusions at
this time.
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Future Directions |
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TopAbstractIntroductionDisruptive Child Behavior...Correlates of Disruptive Child...African American Children and...Correlates of Disruptive Child...Differences Between African...ParentingTreatment IssuesFuture DirectionsReferences |
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The preceding discussion has highlighted several unique features pertaining to the assessment and treatment of young African American children. Despite the identification of cultural differences in child development, parenting, the presentation of behavior problems, and the assessment of behavior problems, little research has been done on how these differences affect treatment using behavioral parent-training programs. Furthermore, even less work has been done by clinicians to incorporate these differences into their treatment programs. Thus, first and foremost, more research is needed to understand the differences between treating African American and Caucasian families using behavioral parent-training programs (Forehand & Kotchick, 1996
). Given the high relationship between race and SES, it might
be helpful if future studies attempt to tease these issues apart by matching
African American participants with Caucasian participants of the same SES or
controlling for SES statistically to determine the additional impact of race
on treatment effectiveness and satisfaction.
Second, clinicians treating young children diagnosed with disruptive
behavior disorders may need to change their practices (e.g.,
Ahia, 1997). For example,
Lindsey and Cuellar (2000)
recommend that clinicians working with African American families consider the
following: (1) the African-American family's unique stressors, worldviews, and
burdens; (2) the possible inclusion of the extended family and religious
interventions; (3) the possibility that the therapist has values or biases or
attitudes that conflict with the client's views of the world; and (4) the
positive factors that lead to competency, self-reliance, and health in the
African American culture. Sue and Sue
(1999) add that the first
sessions may be particularly crucial in working with African American
families. For counselors of a different race, it is often beneficial to ask
the clients about their reactions to working with a therapist of a different
ethnic background. Establishing trust in the initial sessions is important and
can be encouraged by being open, direct, and authentic
(Sue & Sue, 1999). It
seems helpful to routinely assess client values related to child behavior and
parenting, as well as preferences involving treatment delivery.
Within the specific realm of behavioral parent training, therapists may
need to conduct modifications as well. For example, the financial and social
stresses associated with African American parenting may require an emphasis on
individual issues such as stress management
(Ross et al., 1998). Also, the
typical sequence for behavioral parent training may have to be modified for
highly stressed families. For these families, learning to engage in positive
play with their children prior to beginning the discipline program may seem an
unnecessary luxury given the many pressures in their lives. Reversing the
order, such that compliance training precedes relationship building, may help
to motivate these families to stay in treatment
(Eisenstadt, Eyberg, McNeil, Newcomb,
& Funderburk, 1993). Along those lines, it has been suggested
that multiproblem, high-stress families will benefit from briefer assessments,
realistic and obtainable goals, and attendance contracts
(McNeil & Herschell,
1998). An idiographic approach seems warranted whereby therapists
could use traditional behavioral parent-training programs as their core for
treatment and modify them based on their clients' needs and values (e.g.,
Toth & Cicchetti, 1999).
Ultimately, it will be important for therapists to incorporate variables
related to ethnicity when identifying target behaviors and structuring
parenting programs in order to serve the needs of the African American
community.
Received January 10, 2001; revision received May 15, 2001; accepted July 1, 2001
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TopAbstractIntroductionDisruptive Child Behavior...Correlates of Disruptive Child...African American Children and...Correlates of Disruptive Child...Differences Between African...ParentingTreatment IssuesFuture DirectionsReferences |
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