1. Recruiting and Retaining “La Familia Latina” in Child and Adolescent Anxiety Treatment Research Armando A. Pina, Claudio D. Ortiz, and Wendy K. Silverman Florida International University, Miami Introduction In 1994 the National Institute of Heath (NIH) issued a mandate that women and members of ethnic minority groups be included in all NIH funded projects (Hohmann & Parron, 1996; United States Department of Health and Human Services, 1994). Despite this mandate, the Surgeon General’s Report on Mental Health in 2002 documented a scarcity of intervention research with ethnic minority populations, particularly with ethnic minority youths. This lack of research is evident in the child anxiety disorders area where 22 clinical trials have been published since 1994. Not one was conducted exclusively with Hispanic/Latino children and adolescents. In addition, there are no empirical studies examining disparities in recruitment and retention of Hispanic/Latino youths and families in intervention trials, including anxiety trials.This is alarming because anxiety disorders are prevalent in Hispanic/Latino youths (about 9%; Bird, 1996) and Hispanics/Latinos are the fastest growing and largest ethnic minority group in the U.S. (U.S. Department of Commerce, 2004). Purpose of the Study Using a sample of 691 families referred to an anxiety disorders specialty research clinic the purpose of the present study was twofold: First, to compare the proportions of families recruited to families retained as a function of ethnicity/race (European American versus Hispanic/Latino). Second, to compare the following 4 groups of families (1) Hispanic/Latino families recruited, (2) Hispanic/Latino families retained, (3) European American families recruited, and (4) European American families retained along sociodemographic (e.g., family income) and clinical (e.g., diagnoses) characteristics. Operational Definitions Recruited families were eligible to participate in the intervention study, completed the pre-intervention assessment phase, but unilaterally decided either not to enroll in the intervention or terminated the intervention prematurely. Retained families were eligible to participate in the intervention study and completed both the pre-intervention assessment phase and the intervention study. Discussion Findings suggest that recruiting and retaining Latino families in intervention research is challenging. Moreover, variables that differentiate families who were recruited from families who were retained were identified (see Table). These variables are important as they might serve to identify families who are likely to discontinue participation in evidence- based research and who thereby do not receive treatments that are likely to be beneficial. Because no specific variables served to identify Latino families who were recruited but not retained, it is important for future studies to examine variables more akin to the sociocultural conditions of Latino families given that Latinos had a lower retention rate than European Americans. Identifying culture specific barriers to participation in evidence based intervention research can also serve as a beginning step toward enhancing service utilization among Latinos. In doing so, clinicians and research practitioners might consider issues outlined below. Cultural Sensitivity of Assessment/Evaluation. Assessment protocols perceived by families as highly structured might have poor face validity among some Latino families, thereby contributing to low retention. Perhaps, retention could be increased by building rapport using a ‘narrative’ assessment protocol followed by the traditional structured assessment procedures used in evidence-based research. Intervention Attractiveness. Latino families might have an intervention format preference. Parents might prefer their youths to participate in interventions delivered in family-format rather than in individual or group format. Also, Latino families might prefer interventions focusing on culturally relevant problems (e.g., school refusal behaviors) rather than an intervention focusing on reducing psychiatric symptoms. Intervention format and preference mismatch might be related to low retention. Effective ways to increase retention (participation) could include targeting culturally relevant problems in the intervention, assessing format preference, and delivering the intervention in the family’s preferred format. Method A total of 691 families (youths 7 to 16 years old) were referred to an anxiety disorders research clinic in South Florida. During initial telephone contact, a trained assistant used a standardized protocol to provide information about the clinic, the assessment, and the anxiety intervention study. Also during the initial telephone contact, information was gathered to determine the family’s eligibility for participation. All participant families signed inform consent forms (assent for child/adolescent). As part of the assessment procedures, parents completed a battery of questionnaires that included the Child Behavior Checklist (Achenbach, 1991). Recruited Retained Latino Euro-American TotalLatinoEuro-American Total Variable (n = 200) (n = 69) (n = 269)(n = 65) (n = 47) (n = 112) χ 2 /F Gender (%) 6.32* Boys56.647.838.2 1 43.136.211.9 1 Girls43.452.232.156.163.817.8 Referred by (%) 7.79* School Counselor60.137.738.3 1 50.831.912.7 1 Health Professional24.731.918.735.449.012.1 Self-referred15.230.413.513.819.1 4.7 Income (%) 7.12* < $ 21.00016.920.610.724.1 9.3 7.1 $ 21.000 – $40.00037.335.322.1 1 25.916.3 8.7 1 > $ 40.00045.844.127.350.074.424.1 Marital Status (%) 8.15** Married56.152.534.569.476.127.2 Not Married43.947.527.8 1 30.623.910.5 1 M SD M SDMSDM SDMSD M SD Youths’ Age10.0 2.95 10.1 2.7310.1 2.899.4 3.0210.22.97 9.7 3.01 ns CBCL Internalizing65.3 (9.7)61.6(10.37)64.5 (9.93) 1 59.8(11.53)60.6(10.35)60.1(11.0) 1 4.72* Externalizing55.0 (12.7)55.2(10.29)55.1(12.13)53.4(10.78)52.0(12.23)52.8(11.41)ns CBCL = Child Behavior Checklist. χ 2 /F values are reported for the main effects comparing recruited versus retained. Values sharing subscripts are statistically significantly different from each other. * p < 0.05. ** p < 0.01. Recruited Retained Latino Euro-American TotalLatinoEuro-American Total Variable (n = 200) (n = 69) (n = 269)(n = 65) (n = 47) (n = 112) χ 2 /F Gender (%) 6.32* Boys56.647.838.2 1 43.136.211.9 1 Girls43.452.232.156.163.817.8 Referred by (%) 7.79* School Counselor60.137.738.3 1 50.831.912.7 1 Health Professional24.731.918.735.449.012.1 Self-referred15.230.413.513.819.1 4.7 Income (%) 7.12* < $ 21.00016.920.610.724.1 9.3 7.1 $ 21.000 – $40.00037.335.322.1 1 25.916.3 8.7 1 > $ 40.00045.844.127.350.074.424.1 Marital Status (%) 8.15** Married56.152.534.569.476.127.2 Not Married43.947.527.8 1 30.623.910.5 1 M SD M SDMSDM SDMSD M SD Youths’ Age10.0 2.95 10.1 2.7310.1 2.899.4 3.0210.22.97 9.7 3.01 ns CBCL Internalizing65.3 (9.7)61.6(10.37)64.5 (9.93) 1 59.8(11.53)60.6(10.35)60.1(11.0) 1 4.72* Externalizing55.0 (12.7)55.2(10.29)55.1(12.13)53.4(10.78)52.0(12.23)52.8(11.41)ns CBCL = Child Behavior Checklist. χ 2 /F values are reported for the main effects comparing recruited versus retained. Values sharing subscripts are statistically significantly different from each other. * p < 0.05. ** p < 0.01. Results Of the 691 families who contacted the research clinic via telephone, 310 (45%) were not recruited for participation in the pre-treatment assessment phase of the intervention [33.6% were Latinos, 11.4% were European American; χ 2 (2) = 12.47, p < 0.01]. The proportion of Latino families recruited (75%, n = 200/265) was significantly larger than the proportion of European American families recruited (59%, n = 69/116); the proportion of Latino families retained (25%, n = 65/265) was significantly smaller than the proportion of European American families retained (41%, n = 47/116) [χ 2 (1) = 9.93, p < 0.01]. The table below shows means, standard deviations, proportions, test statistics values, and statistical significance from tests comparing families recruited to families retained across the two ethnic groups. Families recruited were significantly different from families retained in that they had lower family income, tended to be referred by school counselors, were seeking help for boys, not married (divorced, separated, single mothers), and reported more internalizing behavior problems using the CBCL. There were no significant differences in terms of youths’ ages or parent reported externalizing behavior problems on the CBCL. There were no statistically significant main effects or interaction effects by ethnicity.