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Disparities in treatment engagement and adherence based on ethnicity have been widely recognized but are inadequately understood. Few studies have examined treatment dropout among Latinx and non-Latinx White (NLW) individuals. Using Andersens Behavioral Model of Health Service Use (A behavioral model of families use of health services. 1968; J Health Soc Behav. 1995; 36:1-10) as a framework, we examine whether pretreatment variables (categorized as predisposing, enabling, and need factors) mediate the relationship between ethnicity and premature dropout in a sample of Latinx and NLW primary care patients with anxiety disorders who participated in a randomized controlled trial (RCT) of cognitive behavioral therapy. Data from a total of 353 primary care patients were examined; 96 Latinx and 257 NLW patients participated. Results indicated that Latinx patients dropped out of treatment more often than NLW patients, resulting in roughly 58% of Latinx patients failing to complete treatment compared with 42% of NLW, and approximately 29% of Latinx patients dropping out before engaging in modules related to cognitive restructuring or exposure, relative to 11% of NLW patients. Mediation analyses suggest that social support and somatization partially explained the relationship between ethnicity and treatment dropout, highlighting the importance of these variables in understanding treatment disparities.

Previous research suggests that there are disparities in mental health service use, and specifically treatment engagement, between Latinx and their non-Latinx counterparts. These disparities in engagement include not only service use (typically defined as past-six month, or past-year service use), but continued participation in psychotherapy following the initial uptake of services, including premature dropout. Although a number of factors have been shown to influence Latinx service use, there is a dearth of research on reasons for ethnic disparities in premature dropout. This dissertation examines reasons for differential premature dropout in a sample of 96 Latinx and 257 non-Latinx White patients receiving cognitive-behavioral therapy for anxiety disorders in primary care. Study 1 utilized Andersen’s Behavioral Model of Health Service Use as a theoretical framework to examine whether individual level pretreatment factors mediate the relationship between ethnicity and premature dropout. Most individual level factors did not explain ethnic disparities in premature dropout, with the exception of low levels of social support and high levels of somatization. Studies 2 and 3 aimed to examine the predictive power of time-varying treatment-specific factors. Study 2 examined the extent to which patient understanding of CBT principles early in treatment explains the relationship between ethnicity and therapeutic engagement. Early CBT understanding mediated the relationship between ethnicity and premature dropout. Early CBT understanding was also associated with other engagement outcomes, including homework adherence, and patient commitment to therapy in the whole sample. Study 3 examined whether anxiety severity and rate of anxiety symptom change over the course of treatment differentially influenced time to dropout between Latinx and non-Latinx White patients. Change in symptoms throughout treatment and their interaction with baseline symptom severity did not explain ethni

Previous research suggests that there are disparities in mental health service use, and specifically treatment engagement, between Latinx and their non-Latinx counterparts. These disparities in engagement include not only service use (typically defined as past-six month, or past-year service use), but continued participation in psychotherapy following the initial uptake of services, including premature dropout. Although a number of factors have been shown to influence Latinx service use, there is a dearth of research on reasons for ethnic disparities in premature dropout. This dissertation examines reasons for differential premature dropout in a sample of 96 Latinx and 257 non-Latinx White patients receiving cognitive-behavioral therapy for anxiety disorders in primary care. Study 1 utilized Andersen’s Behavioral Model of Health Service Use as a theoretical framework to examine whether individual level pretreatment factors mediate the relationship between ethnicity and premature dropout. Most individual level factors did not explain ethnic disparities in premature dropout, with the exception of low levels of social support and high levels of somatization. Studies 2 and 3 aimed to examine the predictive power of time-varying treatment-specific factors. Study 2 examined the extent to which patient understanding of CBT principles early in treatment explains the relationship between ethnicity and therapeutic engagement. Early CBT understanding mediated the relationship between ethnicity and premature dropout. Early CBT understanding was also associated with other engagement outcomes, including homework adherence, and patient commitment to therapy in the whole sample. Study 3 examined whether anxiety severity and rate of anxiety symptom change over the course of treatment differentially influenced time to dropout between Latinx and non-Latinx White patients. Change in symptoms throughout treatment and their interaction with baseline symptom severity did not explain ethni

Parental variables likely have important and bidirectional influences on the etiology of child anxiety. Although some child-focused cognitive-behavioral therapy (CCBT) anxiety trials have found vicarious improvements among parents who participated in their children's treatment, this is an understudied area. We hypothesized that parental variables (psychopathology, stress, and burden) will significantly decrease from pre-to post-CCBT and will be associated with child treatment response. We explored whether intervention delivery method-in-person CCBT versus parent-mediated bibliotherapy-influenced vicarious parental improvements. Parental variables decreased from pre- to post-CCBT and were associated with child treatment response. Effects did not interact with delivery method. Parent participation in anxiety CCBT may result in vicarious improvements for parents.

The present study examines how both between group (i.e., ethnic group membership) and within group cultural factors (i.e., nativity status, age of immigration, and perceived discrimination) may contribute to anxiety and related symptoms in Latinx with anxiety disorders. Baseline data were examined from patients who participated in one of the largest intervention studies for adults with anxiety disorders in primary care settings; 196 Latinx and 568 NLW (non-Latinx White) patients participated. Proportions of anxiety disorders were similar between Latinx and NLWs; however, Latinx, on average, had a greater number of anxiety disorders than NLWs. Levels of anxiety and depression symptom severity, anxiety sensitivity, and mental functional impairment were similar between the ethnic groups. Latinx expressed greater somatization and physical functional impairment than NLWs. Among Latinx, perceived discrimination, but not other cultural variables, was predictive of mental health symptoms while controlling for age, gender, education, and poverty. Overall, these findings suggest more similarities than differences in types and levels of anxiety and anxiety-related impairment, with some important exceptions, including greater levels of somatization and physical functional impairment among Latinx patients. Further, perceived discrimination may be an important factor to consider when examining risk for greater symptom burden among Latinx with anxiety.

IntroductionExternalizing disorders are more prevalent in rural than urban settings and account for disproportionately high mental health service costs for rural adolescents. Although cultural stressors such as discrimination have been associated with externalizing problems in ethnic minority youth broadly, this relationship is understudied in Latinos, particularly those in rural settings. Further, though the associations of family processes such as familism and family conflict have been studied in relation to youth externalizing symptoms, whether these processes change in the face of adolescent discrimination stress remains unknown.MethodsA moderated multiple mediation model was used to examine the association between perceived discrimination, externalizing symptoms, and the indirect effect of family factors (familism, and family conflict) in a large sample (n = 455) of rural Latino youth. We also evaluated whether indirect and direct effects of discrimination on externalizing symptoms differed in boys versus girls.ResultsFamilism and family conflict each independently mediated the relationship between discrimination related stress and externalizing symptoms. However, discrimination had a direct effect on externalizing symptoms for boys only. In girls, this association held only when family factors were accounted for. Post-hoc analyses reveal that the moderating effect of sex on discrimination is driven by differences in rule-breaking behavior, as opposed to aggressive behavior.ConclusionFindings suggest that discrimination is associated with changes in the family environment which in turn invoke elevated risk for externalizing problems. Further, family-focused interventions that address externalizing problems may be especially effective for adolescent girls.

BackgroundStigma has been frequently cited as a barrier to service use for various mental health problems. Studies suggest that stigma may be greater for childhood mental health problems that are perceived as more atypical.AimsThis study utilized a mixed methods research design (qual + QUAN) to examine parental endorsement of stigma and its impact on service utilization among children with significant anxiety-a common childhood problem frequently perceived as normative.MethodsSemi-structured qualitative interviews were conducted with 29 parents of anxious children. Qualitative data were coded using a grounded theory approach, and stigma-related responses were examined for emergent themes. Quantitative data was analyzed with frequency counts and chi-square analysis.ResultsStigma related to children's anxiety symptoms and seeking mental health services was reported by 41.3% (n = 12) of parents. Emergent themes included: 1) Parental Concern for Negative Consequences, 2) Parent Internalized Stigma, and 3) Negative Associations with Mental Health Treatment. Latino parents discussed stigma more frequently than non-Latino White parents (70% vs. 17.6%, respectively, X2(1, N = 27) = 5.33, p < 0.05).ConclusionsAlthough anxiety is a common childhood problem, stigma is still frequently reported by parents and may be an important barrier to mental health service use, especially among Latino youth.