Psychological Association, 2017b).
Ethnicity and SES can interact to place children at greater risk for other psychological problems. For example, behavior therapy with parents is one of the most effective treatments for children who are oppositional and defiant toward adults. However, participation in behavior therapy is poor among low-income, ethnic minority parents. Even when services are provided at a convenient location, and parents are offered free transportation and childcare, less than one-third of parents who are eligible actually participate in treatment. Parents typically report a lack of time and high levels of stress as the main reasons for not taking advantage of these services (Gross, Breitenstein, Eisbach, Hoppe, & Harrison, 2015).
Recently, researchers have tried to use families’ social–cultural backgrounds to increase participation in therapy and enhance the effectiveness of treatment. Culturally adapted treatment involves modifying evidence-based psychotherapy to fit families’ social–cultural context. Therapists listen to families’ backgrounds and immediate needs to make treatment practical and relevant given their current strengths and challenges (Pina, Polo, & Huey, 2019).
Examples of Cultural Adaptations
The Chicago Parent Program is an example of a culturally adapted treatment designed for ethnic minority, low-income families with oppositional and defiant children. It is based on a behavior therapy program for parents. The original program teaches parents to reinforce appropriate child behaviors, such as attention and compliance, and to manage children’s behavior problems in a consistent manner. In each session, parents watch videotaped vignettes of caregivers demonstrating parenting techniques. Parents identify and discuss effective child-rearing strategies and provide support to each other as they attempt to implement these techniques with their own children during the week. The original program was highly effective for middle-SES White families but much less effective for ethnic minority, low-income families (Gross et al., 2015).
Researchers adapted the program to meet the needs of low-income African American and Latino parents living in urban settings. After researchers consulted with parents, they modified the skills taught in the program to make them more accessible and relevant to parents in their community. For example, they focused on skills that emphasized compliance and child safety—skills important to families living in a busy city. They also reframed the lessons about the use of physical discipline (e.g., spanking), which many ethnic minority parents viewed as culturally appropriate and important to childrearing. The researchers created new videotaped vignettes, with African American and Latino parents in more culturally relevant settings. One video demonstrated how to manage child misbehavior at a laundromat; another video addressed handling multigenerational parenting conflicts. An evaluation of the program showed that it had lasting effects on parents’ and children’s behavior. More than 90% of parents reported feeling very satisfied with their participation and 88% said they would highly recommend it to a friend (van Mourik, Crone, de Wolff, & Reis, 2018).
Review
The APA has developed guidelines to help clinicians adapt treatment to meet the needs of children and families from multicultural backgrounds. At the heart of these guidelines is the notion that a child’s identity is influenced by multiple ecological systems.
Psychologists use the term intersectionality to describe the way social–cultural factors interact to shape children’s identity and either promote or hinder their development.
Culturally adapted treatment involves tailoring evidence-based therapies to fit family’s social–cultural backgrounds, expectations, needs, and strengths.
4.3 The Efficacy and Effectiveness of Child Psychotherapy
How Does Child Psychotherapy Differ From Adult Psychotherapy?
Child psychotherapy and adult psychotherapy differ in several ways. First, there are often motivational differences between youths and adults. Most adults refer themselves to therapy; by the time they make the initial appointment, they are at least partially motivated to change their behavior. Indeed, some evidence suggests that the very act of seeking treatment and making an initial appointment is itself therapeutic (Nathan & Gorman, 2016). In contrast, children and adolescents are almost always referred by other people, especially parents and teachers. Youths seldom recognize the severity of their behavioral, emotional, and social problems and they typically show low motivation to change. Most therapists initially try to increase children’s willingness to trust the therapist and participate in treatment (Dean, Britt, Bell, Stanley, & Collings, 2017).
Second, cognitive and social–emotional differences between children and adults can influence the therapeutic process. Most forms of child and adolescent therapy are downward extensions of adult therapeutic techniques. However, by virtue of their youth, children and adolescents often lack many of the cognitive, social, and emotional skills necessary to fully benefit from these techniques. For example, cognitive therapy depends greatly on clients’ ability to engage in metacognition, that is, to think about their own thinking. However, metacognitive skills develop across childhood and adolescence; younger children may find cognitive therapy too abstract and difficult. Similarly, cognitive and psychodynamic therapies often rely on verbal exchanges between client and therapist. Younger children, and youths with limited verbal abilities, may have difficulty participating in these forms of therapy (Kendall, 2018).
Third, the goals of therapy often differ for children compared to adults. In adult psychotherapy, the primary objective is usually symptom reduction. Most therapists and clients consider treatment to be successful when clients return to a previous state of functioning. In therapy with children and adolescents, return to previous functioning is often inadequate. Instead, the goal of child and adolescent therapy is to alleviate symptoms while simultaneously promoting children’s development. For example, a child with ADHD might participate in behavior therapy and take medication to alleviate his hyperactivity and inattention. However, these behavior problems have likely alienated him from classmates. Consequently, the therapist might have an additional goal of helping the child gain acceptance in the classroom and overcome a history of peer rejection.
Fourth, children and adolescents often have less control over their ability to change than do adults. Adults usually have greater autonomy over their behavior and environmental circumstances than do children. For example, a woman who is depressed might decide to exercise more, join a social support group, practice meditation, change jobs, or leave her partner. However, a child who is depressed because of his parents’ marital conflict is less able to alter his environment. Although he might decide to exercise or participate in extracurricular activities, he is unable to leave home or get new parents. Instead, the boy’s social–emotional functioning is closely connected to the behavior of his parents. Consequently, the boy’s capacity to change is directly associated with his parents’ involvement in therapy.
Finally, children and adolescents are more likely to have multiple psychiatric conditions compared to adults. Among youths in the community, approximately 40% who have one disorder also have a second disorder. Among youths referred to clinics, rates of comorbidity range from 50% to 90%, depending on the age of the child and the specific problem. Clinicians who treat children and adolescents must address multiple disorders simultaneously, often without the zealous participation of their young clients (Weisz, 2014).
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Children are often less motivated than adults to participate in therapy and may lack the cognitive or self-regulation skills necessary to participate in many therapies originally designed for adults.
Whereas adult psychotherapy focuses largely on symptom reduction, child psychotherapy
