Epidemiological estimates suggest that approximately 20 % of youth living in the United States (U.S.) have an emotional or behavioral disorder (Merikangas et al. 2010a). Despite these high prevalence rates, studies suggest that less than half youth in need of mental health services actually receive them (Kataoka et al. 2002; Merikangas et al. 2010b, 2009). Ethnic minority populations, including Latino children and adolescents, are especially unlikely to seek and receive mental health services, despite increased level of risk (Flores 2010). From a public health perspective, these are sobering findings, especially since the Latino population in the U.S. represents the largest and most quickly growing ethnic minority group in the U.S. (USCB 2012).

Although increased attention has been paid to existing mental health care disparities for Latino youth and their families (Flores 2010), there continues to be serious concern that the current mental health system is not prepared to meet the needs of this growing population (McKay and Bannon 2004). Although researchers have identified a multitude of factors that contribute to patterns of mental health service utilization more broadly, few studies have examined them specifically for Latino families participating in youth mental health services. Given that children’s involvement in mental health services often relies on the behaviors and perceptions of caregivers and other factors, it is important to consider contextual influences on children’s mental health needs and service use (Pescosolido et al. 2008). Ultimately, the goal of the current review is to provide an empirically supported body of knowledge from a social-ecological framework (Bronfenbrenner 1979) to guide efforts to improve treatment retention, engagement, and response for Latino youth and their families. More thorough description and understanding of these contextual influences will help to highlight factors and processes that must be attended to in working to improve Latino family participation in youth mental health services, especially in the context of developing more culturally responsive treatments for Latino youth and their families. It is our hope that this information will help to guide efforts among mental health care providers, administrators, and policy makers to promote improved mental health services for Latino youth and their families.

In order to underscore the dire need for research and action focused on addressing existing disparities in mental health care and treatment, the review begins with a summary of the Latino population in the U.S. and mental health, including service utilization. A comprehensive review of the various components of family participation in mental health services will then be provided, with particular emphasis on Latino families. Drawing from various models that are included in the review to better understand elements of treatment participation (e.g., Andersen 2008; Becker et al. 2015; De Los Reyes and Kazdin 2006; Haine-Schlagel and Walsh 2015; Hoagwood et al. 1996; Staudt 2007), the current review presents a multi-faceted, multidimensional conceptualization of Latino family participation in mental health services. Using a social-ecological framework (Bronfenbrenner 1979), a summary of research on youth mental health services will then be provided. This includes examining factors from various levels, including the macrosystem (culture), exosystem (community), microsystem (mental health system and family), and individual (parent and child; Bronfenbrenner 1979). Clinical implications and recommendations will be discussed, and an integrated, conceptual model will be presented. Not only will this model help to highlight the way in which treatment retention, engagement, and response are conceptually linked, but it also outlines the various contextual factors that impact Latino family participation in youth mental health services. This model is intended to guide future research and help to inform efforts to improve Latino family participation in youth mental health services.

Before proceeding, it is important to clarify certain aspects of the current review. First, the authors’ use of “Latino” refers to individuals of Latin American ancestry or origin, regardless of generational status. That said, much of the research that is presented in the current review is thought to best describe Latino families that are more closely oriented to traditional Latino culture, a subset of the Latino population in the U.S. that is thought to face an increased number of barriers to mental health services. Also, it is important to note that participation/utilization of mental health services is thought to encompass processes related to both help seeking and “help getting” (Cauce et al. 2002, p. 44; McKay and Bannon 2004). Although existing research has advanced the body of work examining factors that impact help seeking for ethnic minority youth (e.g., Cauce et al. 2002; Eiraldi et al. 2006), this research has not specifically been focused on Latino youth and their families. Thus, the current review aims to build on existing work, reviewing factors that may influence participation in mental health services at-large. Although the current review primarily focuses on the variables involved once a family has sought help, these factors and processes may also be pertinent to help seeking as well. Finally, it is important to note that families may seek mental health services in different ways, including use of informal (i.e., family members, friends, religious leaders, and folk healers), collateral services (i.e., school and juvenile justice systems) and formal mental health services (i.e., psychiatrists, psychologists, and social workers; Cauce et al. 2002). Although research indicates that many families from ethnic minority backgrounds utilize informal mental health care services (Garland et al. 2005), the current review aims to focus on Latino family utilization of formal mental health services within a social-ecological framework (Bronfenbrenner 1979).

Latino Population in the U.S. and Mental Health

Latino Population in the U.S.

According to the U.S. Census Bureau, nearly 40 % of children living in the U.S. are projected to identify as Latino by 2060 (USCB 2012). The Latino population in the U.S. is a diverse, multicultural group, representing various racial/ethnic backgrounds and cultural and ethnic traditions (USCB 2012). Compared to other ethnic groups in the U.S., the Latino population is relatively young, often faces significant sociocultural challenges, and is more likely to be living in poverty (DeNavas-Walt and Proctor 2014). Although the Latino population in the U.S. consists of US-born citizens, foreign-born immigrants, and refugees, many Latino individuals and their families have recently immigrated to the U.S. In fact, research suggests that approximately 40 % of the Latino population in the U.S. entered the country in 2000 or later (USCB 2013). Thus, many Latino youth and their families face many challenges associated with being part of an ethnic minority group and operating within a host culture that may differ from their ethnic culture of origin in many ways (Gonzales et al. 2009).

Mental Health Among Latino Youth in the U.S.

The tremendous growth of the Latino youth population in the U.S. presents some unique challenges for the current mental health system. In fact, some researchers claim that providing effective and appropriate mental health services for this growing population is one of the major public health concerns of our time (McCabe 2002). Despite the increased attention that has been paid to children’s mental health and service utilization in the past decade, disparities continue to persist (Flores 2010). Despite disproportionate levels of health risk factors and increased likelihood of developing mental health problems, Latino youth and their families demonstrate significant underutilization of mental health care services (Flores et al. 2002; Merikangas et al. 2010a). Research indicates that the high rates of environmental stressors, such as acculturation, discrimination, and socioeconomic risk, place Latino youth at greater risk of developing psychosocial problems, including mental health disorders and risky behaviors (Gonzales et al. 2009).

Mental Health Service Utilization among the Latino Population in the U.S.

Although there are mixed findings regarding actual prevalence rates of mental health disorders among Latino youth (e.g., Guevara et al. 2006; Kataoka et al. 2002), research indicates that racial/ethnic disparities related to the quality and use of mental health care services continue to persist (U.S. Department of Health and Human Services [DHHS] 2001). Specifically, Latino youth are less likely than non-Hispanic White (NHW) youth to receive formal mental health services (Zimmerman 2005) despite increased risk for developing mental health problems (Gonzales et al. 2009). Service use disparities can even be found among some of the most high-risk youth, including those engaged in substance abuse treatment programs and child welfare, juvenile justice, and special education systems (Garland et al. 2005). Unfortunately, even when Latino youth and their families seek services, they are more likely to receive inadequate care. This includes a lower likelihood of receiving evidence-based interventions (DHHS 2001) and an increased likelihood of having poor interactions with health care providers, likely due to communication difficulties, cultural differences, and provider stereotypes and stigmatized attitudes (Alegría and Woo 2009; Lee et al. 2009; Shavers et al. 2012). Given existing disparities in the accessibility and quality of mental health services, there is a crucial need to work to improve mental health services for Latino youth and their families.

Overview of Latino Family Participation in Youth Mental Health Services

In order to develop a better understanding of the basic components of Latino family participation in youth mental health services, research on treatment retention, engagement, and treatment response will be examined. These constructs are considered to be integral parts of health care utilization (e.g., Andersen 2008; Haine-Schlagel and Walsh 2015; Staudt 2007). However, these components are not well understood in the context of child mental health, especially for Latino youth and their families. Based on the models and conceptual frameworks presented below, the current review conceptualizes treatment engagement as a multidimensional construct, which consists of various components including treatment retention. These aspects of treatment engagement ultimately are thought to impact treatment response (Becker et al. 2015; Haine-Schlagel and Walsh 2015; Staudt 2007). Treatment response also is considered to be a multidimensional construct and includes various measurable outcomes across various domains (Andersen 2008; De Los Reyes and Kazdin 2006; Hoagwood et al. 1996, 2012). Thus, the following section will provide a summary of research on treatment retention, engagement, and response, including definitions, current conceptualizations, and clinical implications.

Definitions and Current Conceptualizations

Treatment Retention

Various definitions of treatment retention have been used in the literature. In intervention research, treatment retention often is defined as the degree of program completion (Ingoldsby 2010). While some studies conceptualize treatment retention as the percentage of individuals or families who complete treatment, other studies define treatment retention in terms of the percentage of individuals who engage in early termination (Barrett et al. 2008). According to a recent review of the literature on treatment dropout in child and adolescent outpatient mental health care, operational definitions vary significantly across studies. Not only has this produced conflicting findings at times, but it also has made it more difficult to advance research in this area (de Haan et al. 2013; Swift et al. 2009).

Given the various definitions of treatment retention that have been used over time, the construct has been measured in a number of ways. Some researchers measure treatment retention according to the number of sessions attended, often using categories of attendance (de Haan et al. 2013). Although this is a common way to assess treatment dropout, the specified number of sessions constituting treatment dropout cannot consistently be defined across studies, and clients are known to demonstrate different speeds of recovery. For example, a client who attends three sessions may experience higher levels of improvement than one who attends 10 or 15 sessions (Swift et al. 2009). Other researchers define treatment dropout according to the number of missed appointments (de Haan et al. 2013). However, missed appointments occur for various reasons, including a reduced need for therapy due to improvement in symptoms/functioning, structural barriers that impede one’s ability to attend therapy, or an unwillingness to discuss termination with one’s therapist (Swift et al. 2009). More recently, treatment dropout has been based on whether a therapist was in agreement with a client’s decision to terminate treatment (de Haan et al. 2013). Although this method may be a more precise way to assess early termination and may help to control inflated treatment dropout rates, it is challenging to assess (de Haan et al. 2013). For example, clients may end treatment when they perceive themselves to have received a certain degree of relief, despite not having met their treatment goals (Barrett et al. 2008). Recently, researchers have begun to assess treatment dropout as termination that occurs before clinically significant change has been met. Although this may be a more accurate measurement in some ways, it also classifies those who fail to make clinically significant change as treatment dropouts, despite ongoing attendance in therapy (Swift et al. 2009). Given that each single method of measuring treatment retention is limited in some way, existing research points to the need for a multimethod, multidimensional assessment.

Treatment Engagement

Similar to that of treatment retention, treatment engagement has not been defined consistently in the literature, and different terms (e.g., treatment participation and engagement) have been used interchangeably across studies (Staudt 2007). Modern theory considers treatment engagement to be a multidimensional construct that involves separate yet related components (Becker et al. 2015; Haine-Schlagel and Walsh 2015; Staudt 2007). Although most studies examining treatment engagement have relied on behavioral indicators of treatment engagement, such as rates of attendance at treatment sessions, more recent theory highlights the need to identify and assess other aspects of treatment engagement (Becker et al. 2015; Haine-Schlagel and Walsh 2015; Staudt 2007). Although attendance at treatment sessions is an important aspect of participation in youth mental health services, researchers do not consider it to be a sufficient measure of engagement (Becker et al. 2015). Other affective and cognitive factors that must be considered include client emotional investment and cognitions regarding therapy, such as expectations regarding treatment and outcomes, motivation for change, and attributions of causality (Becker et al. 2015; Haine-Schlagel and Walsh 2015; Staudt 2007). Becker et al. (2015) consider these factors to make up the “cognitive preparation” dimension of treatment engagement (p. 31). Recently, researchers have emphasized the importance of distinguishing between the different components of engagement, as some families may attend sessions without being fully invested in the therapeutic process (Haine-Schlagel and Walsh 2015). According to the conceptual framework proposed by Staudt (2007), attitudes regarding treatment are the “heart” of engagement (Staudt 2007, p. 189), such that behavioral indicators of engagement in child mental health treatment (i.e., attendance, participation in treatment sessions, and homework completion) seem to depend on caregiver attitudes and beliefs regarding treatment.

Existing research highlights the need to conceptualize and assess treatment engagement as a multidimensional construct, including behavioral, affective, and cognitive components. In the context of child mental health, researchers suggest that parental engagement may be of particular importance given the unique role that parents (and other caregivers) play in initiating and sustaining participation in youth mental health services. Additionally, many evidence-based treatments for youth with mental health problems utilize parent- or family-focused interventions to work toward therapeutic change (Haine-Schlagel and Walsh 2015). Additionally, although treatment engagement is thought to be a product of the interaction between its various components, most models assume unidirectional, linear relations. For example, the Staudt (2007) model suggests that provider behaviors impact the cognitive and behavioral components of client engagement, but it does not account for the way in which these factors impact provider behavior as well. Thus, there is a need for models that account for the bidirectional nature of these relations as well.

Treatment Response

Similar to that of treatment retention and engagement, modern conceptualization of treatment response recently has expanded. Historically, many studies have relied on the reduction of mental health symptoms to demonstrate efficacy for mental health care treatments (e.g., David-Ferdon and Kaslow 2008; Pelham and Fabiano 2008). However, modern conceptualization suggests that treatment response is a complex, multifaceted construct, and therapeutic change cannot necessarily be examined with a single measure or assessment tool, such as parent ratings of child symptoms (De Los Reyes and Kazdin 2006; Hoagwood et al. 2012). The Range of Possible Changes (RPC) Model developed by De Los Reyes and Kazdin (2006) accounts for the multidimensional nature of intervention change and highlights the need to utilize multiple informants, various outcome measures, and different analytic strategies when examining treatment outcomes. The RPC Model purposely does not propose specific treatment outcome domains, as these variables are thought to vary based on the construct of interest (De Los Reyes and Kazdin 2006).

More recent models have expanded upon the multidimensional nature of treatment response by working to identify specific treatment outcome domains. For example, the most recent iteration of the Behavioral Model of Health Services Use (BMHS), a model that has long been used to understand utilization and retention in health care services, proposes that treatment response is comprised of one’s objective and perceived health status and treatment satisfaction (Andersen 2008). Although the BMHS originally was designed for use with the NHW population, it also recently has guided frameworks for understanding participation in mental health services among individuals from ethnic minority individuals (e.g., Eiraldi et al. 2006; Zerr and Pina 2014). It is noteworthy that differences often exist between one’s objective and perceived health status (Andersen 2008), which may be due to some of the sociocultural factors described below. In addition to the BMHS, the Symptoms/Diagnoses, Functioning, Consumer Perspectives, Environments, and Systems (SFCES) Model, as proposed by Hoagwood et al. (1996, 2012), has provided further description of child mental health treatment outcomes. According to most recent version of the SFCES Model, treatment outcome domains include child symptoms and diagnoses, as measured by multiple informants across various settings; parent symptoms and diagnoses; child functioning/impairment, as measured by multiple informants across various settings; consumer-oriented perspectives; interpersonal/environmental contexts; services/systems; and other health-related factors (Hoagwood et al. 2012). While many of these domains are focused on child and family outcomes, other domains may be used to describe treatment outcomes on a larger scale (Hoagwood et al. 1996). For example, the consumer perspectives domain reflects the subjective experiences of children and their families, including quality of life, treatment satisfaction, and family distress. The interpersonal/environmental contexts and services/systems domains include therapeutic change that take place within children’s primary environments and systems at-large, including their homes and schools, service provision, and health care institutions (Hoagwood et al. 1996).

In summary, modern conceptualization emphasizes the multifaceted nature of treatment response and the need to move beyond assessment of symptom reduction by utilizing a multi-informant, multidimensional assessment of therapeutic change. Although the majority of existing studies have only to been to examine a limited number of the treatment outcomes due to measurement challenges and limited resources, more comprehensive assessments of treatment response is needed in order to develop a more comprehensive, pertinent body of literature on child/adolescent mental health (Hoagwood et al. 2012). Additionally, as with treatment retention and engagement, there is a dire need to examine the way in which existing models and frameworks of treatment response pertain to family participation in youth mental health services, especially for Latino families. Existing models generally fail to acknowledge the role of sociocultural factors, which limits their ability to generalize to ethnic minority populations, including the Latino population in the U.S. (García Coll et al. 1996).

Rates of Latino Family Participation in Youth Mental Health Services

Treatment Retention

Research demonstrates that many children and their families fall out of treatment before receiving the recommended intervention. In fact, of the relatively small percentage of youth who seek mental health services, approximately 30–75 % of children and adolescents terminate prematurely (see de Haan et al. 2013 for a review). Although the emergence of outpatient community-based mental health clinics was meant to mitigate some of the factors that have been linked to early termination, such as long waiting lists and economic disadvantage, rates of treatment dropout largely have not improved in the past 50 years (Barrett et al. 2008). Retention rates for ethnic minority families are especially concerning, as studies indicate that Latino children are more likely than NHWs to engage in early termination (Huey 1998). According to a nationally representative sample of adults participating in outpatient mental health services, research suggests that Latino individuals are significantly more likely than NHWs to drop out of treatment after the third or later visit (Olfson et al. 2009). Multiple factors likely influence the high rates of early termination among Latino families participating in youth mental health services, and there is growing understanding that traditional mental health services may need to be modified in order to improve retention rates and accommodate the needs of the growing population (McCabe et al. 2005).

Retention rates in the child mental health literature vary significantly. Methodological issues, including inconsistent operational definitions and assessment, seem to account for the discrepancies that exist across studies. It is noteworthy that research examining rates of treatment dropout among families participating in youth mental health services primarily has been examined in efficacy studies that have been conducted as part of randomized-control trials with NHWs (see de Haan et al. 2013 for a review). Thus, it may not be possible to generalize the results of these studies to outpatient mental health settings and families from diverse cultural backgrounds, including Latino youth and their families (de Haan et al. 2013). Unlike effectiveness studies, efficacy studies are known for their strict selection criteria, high degree of standardization and treatment fidelity, and use of highly trained staff, all of which results in lower treatment dropout rates (de Haan et al. 2013). Unfortunately, the strict selection guidelines that historically have been employed do not promote the inclusion of ethnic minorities, families with low SES, and comorbid mental health conditions (de Haan et al. 2013; Garland et al. 2013). Even when ethnic minorities are included in efficacy studies, research indicates that they may not be adequately representative (i.e., small sample sizes and overrepresentation of English-speaking, highly acculturated Latino individuals; Huey and Polo 2008). Thus, more research is needed to understand treatment retention for a more representative population of Latino youth and their families participating in child mental health.

Treatment Engagement

Given that treatment engagement has not been defined or measured consistently across studies, available data on rates of treatment engagement in youth mental health services also are limited. Studies examining treatment engagement for Latino families specifically are even more limited. According to a recent review of studies that examined parental engagement in child and family mental health treatment, rates of engagements varied significantly. Some of the factors that appeared to impact the differential rates of parental engagement included the specific treatment that was utilized, the extent to which improving parental engagement was a study aim, the population being studied, and the point in which rates of parental engagement were assessed (Haine-Schlagel and Walsh 2015). For example, one of the studies that was included in the review specifically examined father engagement in youth mental health services (Fabiano 2007), results of which may not generalize to other caregivers (Haine-Schlagel and Walsh 2015). In general, research demonstrates that ethnic minority families, especially those from low SES backgrounds, generally demonstrate poorer engagement and compliance in child therapy services compared to NHWs (McCabe 2002; Reyno and McGrath 2006). In order to develop a better understanding of existing treatment engagement discrepancies for Latino youth and their families, more culturally sensitive research is needed.

Clinical Implications of Poor Treatment Retention and Engagement

Early termination among families participating in youth mental health services has been linked to negative treatment and service delivery outcomes. From a clinical perspective, dropping out of treatment before receiving the prescribed intervention weakens treatment effectiveness. For example, children who terminate therapy prematurely may not receive an adequate amount of the intervention, placing them at greater risk for failing to obtain the desired effects (Barrett et al. 2008). Unfortunately, those who appear to be in greatest need of receiving mental health services, such as ethnic minority families of lower SES background and families with pervasive mental health problems, are most likely to terminate treatment prematurely and often demonstrate the poorest long-term treatment outcomes (Snell-Johns et al. 2004). Premature termination poses negative implications for service delivery as well. Not only has it proven to be costly and an ineffective use of mental health resources, high levels of attrition require significant levels of staff time and operating costs, which may lead to a loss of potential revenue staff productivity (Barrett et al. 2008; Klein et al. 2003; Nock and Kazdin 2005). Premature termination also contributes to long waitlists, which limit the number of people that can be seen, reinforce negative perceptions of mental health care agencies, and delay mental health treatment for families in need of services. Unfortunately, this may lead to a worsening of symptoms and/or decreased interest in pursuing mental health treatment for these families (Barrett et al. 2008).

Unlike treatment retention and response, the link between other indicators of treatment engagement and response is not well documented for families participating in youth mental health services, likely due to the limited number of studies that have been conducted on the subject (Nix et al. 2009). However, existing research suggests that both child and parent participation in services is associated with improved treatment outcomes (Dowell and Ogles 2010). In particular, high levels of investment and engagement in treatment among ethnically diverse families participating in youth mental health services have been associated with improved treatment response (Baydar et al. 2003; Nix et al. 2009). Available research suggests that specific components of parental engagement, such as the quality of parental engagement, may be especially pertinent to treatment response. Nix et al. (2009) determined that the quality of parental engagement, as opposed to parental attendance, predicted positive treatment outcomes in an intervention centered on improved parenting, including more favorable perceptions of their children, increased parental warmth and school involvement, and decreased use of physical punishment. Although these studies provide a good foundation of knowledge on the relation between treatment retention, engagement, and response, few studies have examined Latino families specifically. Thus, more research is needed to explore these factors in the context of mental health services for Latino youth and their families.

Overview of Contextual Factors on Latino Family Participation in Youth Mental Health Services

There are various conceptual factors that mental health care providers, administrators, and policy makers must take into account when working to understand and improve Latino family participation in youth mental health services, including treatment retention, engagement, and response. Given that mental health care is provided within a multi-level context (Garland et al. 2013), the current review is guided by a social-ecological framework (Bronfenbrenner 1979) and presents information in this way. However, before providing a summary of the contextual variables of interest, the current review provides a summary of some of the key models that have been used to explain the influence of contextual factors on mental health service utilization more broadly (e.g., Andersen 2008; Barrett et al. 2008; Olin et al. 2010; Owens et al. 2002; Snell-Johns et al. 2004; Staudt 2007). Although these models were not designed to understand the influence of contextual factors on Latino family participation in youth mental health services specifically, they provide a framework for understanding the way in which these and other factors impact Latino youth and their families participating in youth mental health services.

Summary of Models Examining Participation in Mental Health Services

As described previously, the BMHS has been used to understand the way in which contextual and individuals characteristics affect health services utilization (Andersen 2008). According to the BMHS, variables that influence service utilization can be categorized as predisposing, enabling, or need factors. Predisposing factors are used to describe the context in which services are sought and the individual seeking services, enabling factors include situations or variables that impede one’s ability to utilize health care services, and need factors are thought to influence one’s perceived or objective need for health care services (Andersen 2008). Predisposing factors at the contextual level may include community structure and overarching societal attitudes toward health, while predisposing factors on the individual level may include an individual’s ethnicity and sex (Andersen 2008). Enabling factors at the contextual level may include available medical resources and health policy, while enabling factors at the individual level may include income level and family support. Need factors at the contextual level may include mortality and disability rates, while needs factors at the individual level may include experienced distress, symptom severity, and diagnosis (Andersen 2008).

Similar to that of enabling factors described in the BMHS, researchers more recently have described factors that hinder or impede treatment participation as barriers to treatment (Barrett et al. 2008). The barriers to treatment model are based on the premise that in order for one to participate in treatment, the perceived need for and benefits of treatment must outweigh perceived demands and stressors (Kazdin and Wassell 2000). Although there is a growing body of research on barriers to treatment in relation to health care utilization more globally, few studies have focused specifically on child mental health care, and research examining barriers for ethnic minority youth is even more limited (Owens et al. 2002). As presented by Snell-Johns et al. (2004), barriers to treatment exist across various levels represented by the social-ecological framework (Bronfenbrenner 1979).

In accordance with the barriers to treatment model, Owens et al. (2002) proposed that there are three categories of barriers that impede participation in youth mental health services: parental perceptions of mental health problems, parental perceptions of mental health services, and structural factors. While parental perceptions of mental health problems may include beliefs regarding the severity of mental health problems or the need for treatment, parental perceptions of mental health services may include stigmatized attitudes regarding treatment and mistrust of mental health care providers. Various examples of structural factors exist, including a lack of available providers, long waiting lists, transportation problems, and lack of insurance (Owens et al. 2002). In testing their model with predominantly African American children and their families, Owens et al. (2002)found that parents with more elevated levels of stress, perceived parenting difficulties, and limited experience with and access to the mental health system were more likely to perceive barriers to child mental health treatment.

More recent models have further expanded current understanding of the factors that impact parental engagement in youth mental health services. According to Staudt (2007), attitudinal engagement among caregivers depends on the perceived relevance/acceptability of treatment, daily stressors, therapeutic alliance with one’s mental health care provider, barriers to treatment, and cognitions and beliefs regarding treatment, all of which may be impacted by provider behaviors (Staudt 2007). Olin et al. (2010) further expanded understanding of parental factors by introducing the importance of social norms and self-efficacy as well. According to this model, parents’ intention to engage in youth mental health services also depends on the social support that they receive from close family members and friends, as well as their beliefs on how successful they may be in navigating the mental health system and participating in treatment (Olin et al. 2010). Existing research suggests that higher levels of social support are linked to improved treatment outcomes in the context of child/adolescent mental health (Dadds and McHugh 1992; Kazdin and Wassell 2000).

In summary, these models suggest that factors that influence family participation in youth mental health services exist across various systems and levels. Although these models have not been applied to Latino families specifically, they help to highlight some of the factors and processes that may strengthen or compromise Latino family engagement in services, which are described in more detail below. For example, various factors may impact Latino family engagement in youth mental health services, including health insurance status, knowledge and experience with the mental health system in the U.S., access to linguistically and culturally appropriate mental health services, and concerns related to the way in which treatment participation may impact immigration status. Latino caregivers’ unique attitudes and beliefs regarding their child/adolescent’s mental health problems and treatment also may impact treatment participation, especially if they maintain strong beliefs that children’s behavioral and emotional problems should be handled within the family unit. Latino caregivers may struggle to remain in treatment for their child/adolescent if they do not feel supported by their close family members and friends or if their perceptions of normative child/adolescent behavior and etiological beliefs differ from that of their mental health provider, which is likely to impact their therapeutic alliance, buy-in, motivation, and engagement. It is our hope that more thorough identification and understanding of these factors will help to guide interventions focused on working to improve treatment retention, participation, and response outcomes for Latino youth and their families.

Summary of Contextual Factors on Latino Family Participation in Youth Mental Health Services

Using a social-ecological framework (Bronfenbrenner 1979), the following section summarizes empirical research on the influence of contextual variables on Latino family participation in youth mental health services. This includes examining factors that exist at the culture, community, mental health system, family, parent/caregiver, and child/adolescent levels. Research examining these factors in relation to treatment retention, engagement, and treatment response will be explored, as well as some of the efforts that have been made to improve Latino family participation in youth mental health services.

Culture

Perceptions of Race, Ethnicity, and SES

In attempting to develop a better understanding of existing mental health care disparities for Latino youth and their families, researchers are plagued by the confounding of race and socioeconomic status (SES; LaVeist 2005). Given that Latino youth and their families in the U.S. are more likely to be living in poverty (DeNavas-Walt and Proctor 2014), it may be especially difficult to separate these factors. In general, research studies involving ethnic minority populations have been criticized for relying on between-group ethnic comparative research designs, such as comparing ethnic minority children from low SES backgrounds to NHW children from middle SES backgrounds and failing to match participants on socioeconomic factors (García Coll et al. 1996). However, research indicates that although race and SES are correlated, they also are independent predictors of health status. In fact, research demonstrates that racial and ethnic disparities persist, even after accounting for SES-related factors (LaVeist 2005). For example, a study examining utilization of mental health services among high-risk youth found that racial/ethnic disparities related to health care utilization persisted after the effects of sociodemographic factors were taken in account. In particular, after controlling for the effects of family income and parent education, racial/ethnic differences were found between ethnic minority and NHW children related to receiving any kind of mental health service and outpatient service use (Garland et al. 2005).

Overarching perceptions of race/ethnicity and SES also may impact utilization of youth mental health services. Discriminatory attitudes, in particular, have been associated with racial/ethnic disparities in health care and health-related outcomes (Shavers et al. 2012). Discrimination has been identified as “actions carried out by members of dominant groups, or their representatives, that have a differential and harmful impact on members of subordinate racial or ethnic groups” (Smedley et al. 2003, p. 523). In addition to other sociodemographic factors, discrimination can be based on one’s ethnicity, race, or SES. Although existing research on Latino youth is scarce, studies show that Latino adults are more likely than NHW individuals to experience perceived racial/ethnic discrimination in the health care setting (D’Anna et al. 2010; Lee et al. 2009; Shavers et al. 2012).

Although discrimination often exists at the individual level, more institutional discrimination or racism can be found in existing policies and procedures as well (Cheng and Goodman 2015; Shavers et al. 2012). Not only has racial discrimination been linked to various negative mental health outcomes in Latino individuals and families, including high levels of psychological distress and internalizing problems, as well as low self-esteem (Ayón et al. 2010; Chou et al. 2012; Moradi and Risco 2006), but it also has been associated with unfavorable health care utilization outcomes. Research suggests that racial discrimination may manifest in health care providers’ stigmatized attitudes and unfair treatment, which may impact the accessibility and quality of health care services (see Shavers et al. 2012 for a review). For example, studies indicate that Latino individuals’ experiences of perceived racial discrimination in health care are associated with poorer self-reported quality of care and patient–doctor communication (Lee et al. 2009; Perez et al. 2009). Unfortunately, these negative experiences in the health care setting lessen the likelihood of receiving health care services, even when a specific need is identified (Lee et al. 2009). Thus, many Latino caregivers may be less likely to seek services for their children/adolescents in need if they have had these kinds of negative experiences in the health care setting.

Perceptions of Mental Health/Treatment

In addition to perceptions of race, ethnicity, and SES, perceptions of mental health have been shown to impact participation in mental health services as well. Mental health stigma, in particular, has been defined as the process that occurs “when elements of labeling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them” (Link and Phelan 2001, p. 377). Stigma often involves negatively perceiving an individual based on his/her affiliation with a group that is perceived to be inferior or subordinate in some way, such as individuals with mental health problems (Heflinger and Hinshaw 2010). Existing research on stigma and mental health has primarily examined stigmatized attitudes endorsed by the public, family, and/or individual. However, more recent conceptualization of mental health stigma in the context of youth mental health services highlights the importance of examining both institutional stigmatization and service providers’ stigmatized attitudes, including mental health professionals, pediatricians, and other health educators (Heflinger and Hinshaw 2010; Mukolo et al. 2010). Additionally, various types of stigma have been identified, including stigma directed toward children with mental health conditions, stigma directed toward individuals associated with a child with mental health problems, and stigma associated with the experience of seeking or receiving help for mental health problems (Mukolo et al. 2010).

Although mental health stigma is pervasive in modern society, research suggests that ethnic minority individuals may be especially likely to endorse mental health stigma and mistrust of health care providers, which likely stem from unique sociocultural beliefs, past experiences of perceived discrimination, and inadequate health care treatment (Armstrong et al. 2007; Corrigan and Watson 2007; DHHS 2001; Keyes et al. 2012). Unfortunately, research suggests that stigma and mistrust serve as barriers to participation in mental health treatment and may lead to an underutilization of available services (Corrigan and Watson 2007; Nadeem et al. 2007). Although research on stigma and youth mental health services for the Latino population in the U.S. is limited, a recent study examining parent-reported barriers to child health services found that stigmatized mental health attitudes among Latino caregivers were a barrier to treatment utilization. In particular, the study found that Latino caregivers were more likely than African American and NHW caregivers to report that stigma-related concerns would delay or impede their ability to seek mental health services for their child (Young and Rabiner 2015). Research suggests that immigration status and fears regarding deportation also may impact participation in mental health services. Not only do these stressors contribute to the development of mental health problems in Latino individuals, but they also may serve as barriers to seeking and engaging in mental health services (Rodríguez et al. 2009; Shattell et al. 2008).

Community

Access and Availability of Mental Health and Community Resources

Researchers have noted various challenges to engaging families in mental health services, especially when there is limited access and availability of mental health and community resources. This is especially evident in more impoverished communities that are plagued by the realities of community stressors, including increased community violence and trauma, psychosocial difficulties, and limited educational and employment opportunities (Gopalan et al. 2010). Not only do these factors place children at greater risk for developing mental health problems, but they also pose challenging barriers to treatment. According to the barriers to treatment models (e.g., Barrett et al. 2008; Kazdin and Wassell 2000; Owens et al. 2002; Snell-Johns et al. 2004), research suggests that various system-level factors may hinder family participation in treatment. Barriers may include psychosocial stressors and external barriers to treatment, including fewer mental health services available, lack of transportation, childcare, scheduling difficulties, and cost (Barrett et al. 2008; Owens et al. 2002; Snell-Johns et al. 2004). For Latino families participating in youth mental health services, external barriers to treatment may be especially salient. For example, a recent study examining family participation in mental health and medical services found that Latino caregivers rated concerns of having to wait for prolonged periods of time before seeing a health care provider, not having sufficient financial resources, and living too far from available services as more inhibiting than African American and NHW caregivers (Young and Rabiner 2015).

Insurance status is another system-level factor that has been identified as a barrier to Latino family participation in youth mental health services, especially since Latino children are more likely than non-Latino youth to be uninsured. According to recent U.S. census data, approximately 12 % of Latino youth are uninsured, as compared to approximately 5 % of NHW children and 8 % of African American and Asian children living in the U.S. (Smith and Medalia 2014). For the Latino immigrant population in the U.S., common challenges to securing insurance include language barriers, a lack of knowledge and experience with the U.S. health care system, misinformation regarding eligibility, and fears related to the way in which receipt of health care may impact immigration status (Berk and Schur 2001; Capps et al. 2002). In the context of child health services for Latino youth specifically, a recent study indicated that parent-reported health insurance concerns were a barrier to treatment. In particular, Latino caregivers were more likely than African American caregivers to report that their insurance’s limited coverage for mental health/counseling would delay or impede their ability to obtain services for their child (Young and Rabiner 2015).

Given the various culture- and community-level factors that may impact Latino family participation in youth mental health services, recent efforts have been made to improve treatment retention, engagement, and response outcomes. Increased integration of mental health services into primary care and educational settings is one of the recent strategies that has been identified. Garland et al. (2013) consider this to be a “promising” approach (p. 14), especially given the Patient Protection and Affordable Care Act’s aim to increase coverage for mental health care services in primary care (Croft and Parish 2013). Research suggests that pediatric primary care visits may be valuable opportunities to identify and treat mental health problems in youth, especially for families who may be less likely to seek formal mental health care services due to stigmatized mental health attitudes and increased barriers to treatment (Stancin and Perrin 2014). Research suggests that there is a high prevalence of behavior and emotional problems in the primary care setting, and many caregivers prefer to seek mental health treatment from primary care providers as opposed to formal mental health care services (Hourigan et al. 2015; Polaha et al. 2011). The use of integrated primary care may be a particularly effective in reaching the Latino population in the U.S., as research suggests that Latino individuals most frequently seek mental health care treatment from their primary care providers (Bridges et al. 2012; Vega et al. 1999). Although treatment outcomes for Latino youth and their families participating in integrated primary care are limited, available research indicates that integrated behavioral health care is an effective method of reducing barriers to treatment for Latino adults, such that Latino adults participating in integrated behavioral health care demonstrate comparable levels of retention, treatment satisfaction, and clinically significant levels of improvement compared to NHWs receiving the same services (Bridges et al. 2014).

Mental Health System

Treatment and Therapist Factors

In addition to community factors, variables related to the mental health system also have been shown to impact Latino family participation in youth mental health services. Treatment and therapy characteristics, in particular, have been shown to impact treatment dropout rates in child mental health care services, although these have received relatively little attention in the literature (Haine-Schlagel and Walsh 2015). According to the review by de Haan et al. (2013), various treatment and therapist factors predicted treatment dropout in child and adolescent outpatient therapy, including a high treatment demands, therapists’ low perceived relevance of treatment, and poor therapeutic relationship. Disruptions in the therapeutic alliance may be due to differing expectations regarding treatment, such as treatment length and realistic degree of improvement (de Haan et al. 2013). Other factors predicted treatment dropout as well, including more cancellations/no-shows, poor therapist characteristics (e.g., low levels of concern, charisma, and support), therapy focus and treatment modality, less organization in therapy, and disruptions in the alliance between the parents, child, and therapist (de Haan et al. 2013). Although a lack of ethnic and/or gender matching proved to be significant predictors of treatment dropout across four studies that were included in the review, the effect size of these predictors was small (de Haan et al. 2013).

Therapeutic Alliance

The therapeutic alliance, a construct that is conceptualized as the bond between therapist and client and the collaborative nature of their relationship, also has been shown to predict family retention in treatment (Karver et al. 2005). For ethnic minority individuals, ensuring ethnic match between client and health care provider is one technique that has been used in psychotherapy order to promote cultural sensitivity and improve patient satisfaction and treatment effectiveness (Karlsson 2005). A recent study found that although Latino individuals initially report a moderately strong preference for therapists of their same ethnicity/race, their final evaluations of the therapist’s effectiveness and traits did not vary significantly according to the therapist’s race/ethnicity (Cabral and Smith 2011). Although existing data suggests that empirical support for ethnic matching is limited and much of the existing literature is plagued by methodological concerns (Cabral and Smith 2011; Karlsson 2005), ethnic matching has been shown to predict better treatment outcomes for Hispanic youth in some cases. For example, a study examining ethnic matching in relation to treatment outcomes for adolescents with substance abuse problems participating in family therapy found that Hispanic adolescents who were matched with therapists of the same ethnicity/race demonstrated significantly better treatment outcomes than non-matched Hispanic adolescents. In particular, non-matched Hispanic youth demonstrated significantly higher rates of substance use at 4 months post-treatment (Flicker et al. 2008b). In the context of Latino mental health treatment, researchers have emphasized the need to better understand why ethnic matching may be helpful at times and what kinds of clients may be especially likely to benefit (Flicker et al. 2008b; Verdinelli and Biever 2013). However, therapists and clients of the same race/ethnicity do not always maintain similar worldviews, and researchers suggest that other therapist factors, such as language, style, cultural competence, and sharing of cultural values, may be important to consider as well (Cabral and Smith 2011; Verdinelli and Biever 2013).

Cultural Competence

Unfortunately, research suggests that a lack of sensitivity and understanding of the way in which cultural and family systems factors impact ethnic minority family engagement in mental health services may contribute to lower levels of engagement among Latino families participating in mental health services (Forehand and Kotchick 1996, 2002). Researchers suggest that this may be a product of the inadequate representation of Latino youth and their families in the child mental health and treatment outcome literature (Flores et al. 2002; Miranda et al. 2005). In order to combat the lack of cultural sensitivity and knowledge in mental health, there has been a growing movement to develop and disseminate culturally adapted treatments for Latino youth and their families. Evidence on the efficacy and effectiveness of culturally adapted interventions is mounting (Barrera et al. 2013; Bernal et al. 2009a; Sue et al. 2009), including interventions designed or adapted specifically for Latino youth and their families (e.g., Domenech Rodríguez et al. 2011; McCabe and Yeh 2009; McCabe et al. 2005; Pantin et al. 2003). For example, the Guiando a Niños Activos (GANA) program, a culturally adapted version of Parent Child Interaction Therapy (PCIT) developed by McCabe et al. (2005) for Mexican–American families of children with behavior problems, has produced promising findings. In particular, families participating in the GANA program demonstrated significantly better treatment outcomes than families participating in treatment as usual, such as higher rates of father engagement and treatment satisfaction, more positive observations of parent–child interactions, and lower levels of child symptoms and parental stress. Although GANA and PCIT families did not significantly differ from each other, researchers suggest that this may be due to the small sample size that was employed (McCabe and Yeh 2009).

Although culturally adapted treatments aim to improve cultural competency at the treatment level, recent efforts have been made to foster cultural competency at the therapist level as well. Research suggests that cultural competency among providers is another variable that may impact treatment retention, engagement, and response in family-based interventions (Kumpfer et al. 2002). At the therapist level, cultural competency is thought to include awareness of how one’s personal beliefs and biases may impact his/her perceptions and behavior, knowledge about the way in which culture may impact a client’s experiences, and strong therapeutic skills, all of which will aid in effective treatment (Sue et al. 2009). For the Latino population in the U.S., therapeutic style may be important to consider in the context of participation in mental health services as well. According to a recent review of factors that impact parental engagement in child and family mental health treatment, higher levels of therapist directiveness were associated with lower levels of parental engagement in youth mental health services (Haine-Schlagel and Walsh 2015). This finding may reflect cultural preferences, as the use of a more directive therapeutic approach has been recommended when conducting therapy with Latino individuals. Research suggest therapist directiveness, when coupled with warmth and positive regard, may be congruent with Latino individuals’ cultural expectations for a higher level of structure in therapy and lead to more favorable treatment retention, engagement, and response (La Roche 1999, 2002).

Family

Sociodemographic Factors

In addition to the various mental health system factors presented above, family factors likely impact Latino family participation in youth mental health services as well. Examining youth mental health services more generally, various demographic and psychosocial factors have been linked to poorer family attendance and parental engagement, including increased family distress, daily stressors, family size, economic disadvantage, and family instability, as well as single-parent status, having a non-biological head of household, and lower levels of social support (Dadds and McHugh 1992; de Haan et al. 2013; McKay and Bannon 2004; Nix et al. 2009). In contrast, living in better home and neighborhood environments, as measured according to factors such as safety, cleanliness, space, and community characteristics, has been associated with improved quality of parental participation in parent management training (Nix et al. 2009). Although these factors have been linked to poorer family participation in mental health services, some specific strategies have been helpful in engaging Latino families from lower SES backgrounds in treatment. For example, the Familias Unidas intervention, a family-focused intervention that aims to strengthen parental investment (i.e., positive parenting strategies, support, and involvement) in their adolescents’ lives and reduce adolescent behavior problems (Coatsworth et al. 2002), has been shown to promote positive engagement outcomes among Latino families from lower SES backgrounds. These engagement outcomes are likely due to some of the culturally based techniques that are used in the Familias Unidas engagement phase, including a home visit with each family to review treatment goals and expectations, helping to motivate parental participation by tailoring the treatment goals to their specific family’s situation, and addressing and working to resolve parent-reported barriers to treatment (Coatsworth et al. 2002).

Family Functioning

Family functioning and family system factors, such as communication and cohesion, also have been linked to family retention, engagement, and response. In fact, researchers have suggested that for ethnic minority families, family functioning is the most salient predictor of family participation in mental health services (Perrino et al. 2001). For example, a study examining Latino adolescents and their families participating in functional family therapy found that differential therapeutic alliance within families (i.e., differing levels of alliance with therapist among family members) predicted poor treatment retention for Latino families participating in therapy but not among NHW families (Flicker et al. 2008a). This finding suggests that differences in therapeutic alliance between members of the same family unit may be more detrimental to Latino family treatment participation than families from other cultural backgrounds. Although more research is needed to understand such differences between ethnic groups, this may be due to the effects of normative family functioning within Latino families, including increased emphasis on familism and social hierarchy within families (Flicker et al. 2008a). Familism is a traditional cultural value that involves family cohesion, loyalty, and dependence on one’s nuclear and extended family. Hierarchical family structure emphasizes that certain members of one’s family, typically parents, elderly individuals, and men, maintain higher levels of power and authority (Chang et al. 2013; Sue and Sue 2013). Given the social hierarchy that exists within many traditional Latino families, researchers suggest that some differences in therapeutic alliance within families may be allowable, such that strong therapeutic alliances with certain family members may be particularly necessary. However, the traditional cultural value of familism also emphasizes closeness and unity. Thus, if certain family members do not perceive therapy to be necessary or helpful, existing research suggests that this may be interpreted as a disruption to family cohesion, which has negative implications for treatment retention for Latino families (Flicker et al. 2008a).

Given these aspects of family functioning in traditional Latino families, certain therapeutic models and approaches have been shown to be especially effective in promoting Latino family participation in youth mental health services. Research suggests that family-focused interventions, in particular, are well-suited for many Latino families in need of mental health services, as they are aligned well with traditional Latino values that emphasize of family unity and closeness (e.g., Coatsworth et al. 2002; Flicker et al. 2008a). Yet, researchers also note that in order to understand the effects of diversity and contextual factors on Latino family participation in youth mental health services, there is a need to adapt existing evidence-based treatments and explore underlying mechanisms of therapeutic change. Researchers suggest that factors such as family racial/ethnic composition and culture must be considered, despite often being neglected in existing research (Bernal and Domenech Rodríguez 2009; Bernal et al. 2009a, b).

Certain family-based therapeutic approaches have shown to promote favorable treatment retention, engagement, and response outcomes for Latino families. For example, Brief Strategic Family Therapy (BSFT; Szapocznik et al. 2003; Szapocznik and Kurtines 1989), a short-term family-focused intervention designed for families of youth with risk-taking and behavior problems, has been proven to be efficacious with Latino families. Not only has BSFT proven to reduce Latino adolescent conduct problems and drug use (Santisteban et al. 2003), but it also has shown to promote high levels of retention and engagement for Latino families participating in therapy (Coatsworth et al. 2001; Santisteban et al. 1996). BSFT works to change maladaptive patterns of behavior within families and involve family members who may be resistant or poorly invested in therapy from the beginning of treatment. Future research aims to address how family-focused interventions, such as BSFT, can promote high levels of treatment retention and engagement and favorable treatment outcomes in real-world settings, especially given some of the complicating factors that community mental health clinics pose, such as high caseloads and limited staff availability (Szapocznik et al. 2012).

Parent/Caregiver Factors

Sociodemographic Variables

Given that parents and other caregivers are primarily responsible for in initiating and sustaining participation in youth mental health services, parental factors are important to consider in the context of mental health services for Latino children/adolescents and their families. Similar to family factors, various parental sociodemographic factors have been associated with family participation in youth mental health services. According to recent review of treatment retention in child and adolescent outpatient mental health care, young maternal age, poor parenting, limited knowledge about a child’s diagnosis, low confidence about doing well in treatment, more parental problems, and increased parental psychopathology predict higher levels of treatment dropout (de Haan et al. 2013). Given that caregivers with higher levels of psychopathology and decreased quality of life are more likely to perceive barriers to youth mental health services (Kazdin and Wassell 2000), this factor may be particularly important in the context of Latino family participation in mental health care services. Research suggests that Latino parents who perceive more barriers to treatment are more likely to drop out of child mental health treatment prematurely (McCabe 2002).

Various parental sociodemographic factors also have been linked to treatment engagement. According to a recent review of parental engagement in child and family mental health care treatment, younger parental age, parental sex (female), participation among both parents, and higher levels of motivation and satisfaction with treatment predicted increased levels of parental engagement in child and family mental health services (Haine-Schlagel and Walsh 2015). In contrast, increased levels of parental psychopathology and poor parenting, as well as lower levels of parental education and job skills, have been associated with decreased levels of parental participation in youth mental health care treatment (Baydar et al. 2003; Haine-Schlagel and Walsh 2015; Nix et al. 2009).

Parental Perceptions

Parental perceptions also have been linked to Latino family participation in youth mental health services, including beliefs about the causes of child mental health problems. For example, research suggests that ethnic minority individuals, including Latino caregivers, are less likely than NHW individuals to believe that their child’s behavior problems are caused by biopsychosocial factors, such as physical causes (Yeh et al. 2004; Yeh et al. 2005). Ultimately, these beliefs may impact future mental health service use, as research suggests that sociological causes of child behavior are not predictive of future service use (Yeh et al. 2005). Differences in etiological beliefs also may cause disruption in the therapeutic alliance. For example, Latino parents and their mental health care providers are likely to maintain different perceptions regarding the cause of their children’s mental health problems (Yeh et al. 2004). Researchers suggest that is these kinds of cultural differences are not taken into account and integrated in some way, Latino parents may be less likely to seek services or remain in treatment, especially if the mechanisms that are expected to produce therapeutic change are not consistent with one’s cultural values and expectations (Yeh et al. 2004). Thus, for many families participating in youth mental health services, it may be especially important to provide psychoeducation about mental health and treatment in order to address parents’ unique perceptions and expectations regarding treatment (Gopalan et al. 2010).

Other parental beliefs that have been linked to higher levels of treatment dropout for families participating in youth mental health services include low perceived relevance of treatment and motivation to participate (Gross et al. 2001; Stevens et al. 2006). Socioeconomic and cultural factors are thought to influence individuals’ perceptions regarding treatment, which may subsequently impact motivation to participate in treatment (Morrisey-Kane and Prinz 1999; Nock et al. 2007). Regarding the Latino population specifically, research suggests that parents of youth participating in psychotherapy who believed that mental health services would be effective were less likely to terminate treatment prematurely (Huey 1998). However, Latino parents who endorsed certain beliefs (i.e., parents should be able to overcome their children’s problems on their own, children’s problems should be addressed with strict discipline techniques, and recovery happens quickly) were more likely to drop out of treatment prematurely (McCabe 2002).

Acculturation and Ethnic Identity

Various parental cultural factors also have been shown to impact Latino family participation in mental health services. Acculturation is one of the primary variables that has been considered, a construct that is defined as the multidimensional process that occurs when individuals from different cultural backgrounds interact with each other and the changes that take place with regards to one’s behavior, beliefs, and values related to one’s ethnic culture of origin and/or U.S. mainstream culture (Marín 1992; Redfield et al. 1936). Drawing from research that has been conducted with Latino adults, there are some inconsistent findings regarding the effects of acculturation on service use. Regarding health care utilization, most studies have found that increased levels of acculturation (i.e., greater orientation to U.S. mainstream culture) are associated with increased service use (Lara et al. 2005). Research examining proxy measures of acculturation, including language use and length of residence in the U.S., have produced similar results. For example, within a sample of Latino immigrant adults, individuals with limited English ability were less likely than individuals with English proficiency to receive mental health services (Kim et al. 2011). Similarly, other research suggests that greater preference for Spanish language use is associated with a lower likelihood of utilizing mental health services (Keyes et al. 2012), and increased time in the U.S. predicts higher rates of health service use (Nandi et al. 2008). These findings likely indicate a greater level of integration into U.S. mainstream society and increased knowledge of how to navigate the health care system in the U.S. (Nandi et al. 2008). Ethnic identity, a related construct that reflects a sense of identification and belonging to one’s ethnic culture of origin and community (Phinney and Ong 2007), has been linked to mental health service use as well. A recent study found that individuals reporting strong Latino ethnic identity were less likely to use mental health services for mood and anxiety disorders, even after controlling for other factors that are thought to influence service utilization (i.e., insurance, income, and severity of symptoms; Keyes et al. 2012).

Many Latino families in the U.S. commonly experience generational acculturation differences. Existing research suggests that Latino youth typically identify or adapt more quickly to U.S. mainstream culture than their parents and elderly family members, which may result in conflicting cultural values and communication problems (Hwang 2006). While Latino youth may perceive their parents to be disconnected and demanding, Latino parents and elders may perceive their children’s mainstream values, behaviors, to significantly contradict to their ethnic culture of origin. Unfortunately, the family conflict that arises from these differences has been associated with negative mental health outcomes for Latino youth, including increased levels of internalizing problems and aggression (Hwang and Wood 2009; Smokowski and Bacallao 2006, 2007). Many of the existing family-focused interventions that have been shown to be efficacious with Latino youth and their families address acculturation conflict throughout the course of therapy in order to promote positive engagement and treatment outcomes (e.g., Coatsworth et al. 2002; Santisteban et al. 2003). For example, the Familias Unidas program works with families to develop more of a bicultural perspective, so as to foster increased understanding between family members and a deeper appreciation for cultural assets associated with both one’s ethnic culture of origin and U.S. mainstream culture (Coatsworth et al. 2002).

Sociocultural Values and Beliefs

In addition to acculturation and ethnic identity, parental sociocultural beliefs are important to consider in the context of Latino family participation in youth mental health services. As previously described, the GANA program identified various traditional cultural values that are likely to impact Latino family participation in mental health services, including familism, respect for authority and hierarchical family structure (respeto), personalismo, collectivism, and adherence to traditional gender roles (McCabe et al. 2005). As previously described, familism emphasizes characteristics of closeness, loyalty, and interdependence with one’s immediate and extended family members. Respect for authority, also known as respeto, highlights the belief that certain individuals and family members warrant higher levels of power and authority, including parents, elderly individuals, and men (Chang et al. 2013; Sue and Sue 2013). Personalismo refers to the importance of establishing trusting, warm interpersonal relationships with others (Altarriba and Santiago-Rivera 1994). Collectivism emphasizes the importance of collaborative relationships, as opposed to those that are based on competition and interpersonal discord (Kashima et al. 1995). Research also suggests that more traditional Latino families are likely to adhere to gender role expectations in which mothers are primarily engaged in caregiving responsibilities (Alegría and Woo 2009). Research suggests that these traditional gender roles may serve as a barrier to father participation in youth mental health services in the Latino community (McCabe et al. 2005), as well as influence parental perceptions of child behavior. For example, more stringent gender role expectations may cause parents to perceive hyperactivity among male children to be acceptable, lessening their perceived need for mental health treatment (Pumariega et al. 2005). However, a study examining a nationally representative sample of school-aged children in the U.S. also found that girls are significantly less likely than boys to receive mental health care treatment for externalizing disorders (Zimmerman 2005). Thus, further research on this topic warranted. Fatalism is another traditional cultural value that has been examined, which refers to the belief that individuals lack of personal control over their life experiences and believe that the occurrence of events to destiny, luck, or a higher power (Anastasia and Bridges 2015).

Although not all of these traditional cultural values have been linked to treatment retention, engagement, and response specifically, they likely impact Latino family participation in youth mental health services in some way, especially if the therapist’s expressed values and/or the therapeutic approach are incongruent with these values. In the Latino adult population, both familism and fatalism have been theorized to serve as barriers to Latino family participation in mental health services (Kouyoumdjian et al. 2003). In the Latino adult literature, familism has been linked to mental health care utilization, such that higher levels of familism and increased levels of family cohesion have been associated with lower likelihood of utilizing mental health services (Chang et al. 2013). For example, a recent study found that family cohesion, an aspect of familism, was related to mental health service use, such that Latino individuals who reported high levels of family conflict and low levels of family cohesion were most likely to use mental health services (Chang et al. 2013). Future research is needed to improve understanding of the relation between familism and mental health service utilization. In particular, increased levels of family cohesion may both provide protective levels of family support and reinforce stigmatized mental health attitudes, including the belief that mental health problems should be handled within the family unit for fear of shame or embarrassment (Chang et al. 2013). Although few empirical studies exist, increased levels of fatalism have been found to be negatively associated with past year medical service utilization in a community sample of Latino adults, and self-reported depressive symptoms have been shown to mediate the relation between fatalism and mental health service utilization (Anastasia and Bridges 2015). Although fatalism may be associated with service utilization to a certain degree, researchers suggest that other factors may be more are better predictors of mental health care utilization in the Latino population in the U.S. (Anastasia and Bridges 2015).

In addition to the substantial linguistic and cultural barriers that exist, many Latino caregivers enter treatment with more normative fatalistic beliefs, limited knowledge and experience with the health system in the U.S., and experiences of being marginalized or discriminated against in U.S. mainstream society (Coatsworth et al. 2002). Unfortunately, these factors likely negatively impact parental self-efficacy and expectations for doing well in treatment, which has been shown to predict treatment dropout in child and adolescent outpatient mental health care (de Haan et al. 2013). Efficacious family-based interventions for Latino youth and their families address these kinds of parental self-efficacy concerns. For example, one of the main goals of Familias Unidas is to work to empower Latino caregivers and their families (Coatsworth et al. 2002). Thus, in order to help families to obtain necessary resources and increase feelings of parental competency and control, Familias Unidas promotes the practice of treating caregivers with high levels of respect and care, encourages caregivers to take active role in treatment, and engages them in collaborative decision-making and problem-solving processes (Coatsworth et al. 2002). Other culturally adapted, family-focused interventions for Latino youth at-risk for behavior problems (Martinez and Eddy 2005) and those diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD; Gerdes et al. 2015) maintain similar perspectives in working to empower Spanish-speaking Latino caregivers. These interventions use specific empowerment strategies, such as referring to group therapists as “entrenadores” (coaches) instead of “parenting experts,” actively engaging parents in therapy sessions with the use of role-play and weekly homework activities, and increasing parental involvement in a school-based intervention by having at least one parent attend weekly check-in meetings at the school with the teacher and therapist (Gerdes et al. 2015; Martinez and Eddy 2005). These kinds of strategies may be particularly helping in empowering certain Latino caregivers and working to promote favorable treatment retention, engagement, and response outcomes.

Child/Adolescent Factors

Sociodemographic/Diagnostic Variables

In the general child mental health literature, research has primarily focused on child sociodemographic/diagnostic factors, and other psychosocial and sociocultural factors have yet to be explored. Research generally suggests that child/adolescent symptoms and functional impairment predict treatment outcomes for youth with emotional and behavioral problems, such that increased severity of symptoms and functional impairment have been associated with worse treatment outcomes (Phillips et al. 2000). It is noteworthy that when examining parent-reported symptoms of child internalizing and externalizing problems, research conducted with Latino youth and their families may be complicated by studies that have shown that Latino caregivers are more likely to underreport symptoms of child psychopathology. Although more research is needed to determine whether this is a product of the way in which symptoms are perceived by caregivers themselves or other factors, such as mental health stigma and barriers to treatment (Eiraldi and Diaz 2010; Guevara et al. 2006), this may complicate findings on parent-reported child mental health symptoms and treatment retention and engagement.

The review conducted by McKay and Bannon (2004) identified various child sociodemographic/diagnostic factors in relation to mental health service use. In particular, child sex, severity of symptoms, impaired functioning, and ethnic minority status were predictive of utilization of mental health services, such that male children, those with higher levels of mental health problems, and youth from ethnic minority backgrounds demonstrated lower rates of mental health service use than their respective counterparts (McKay and Bannon 2004). Results on child age and severity of functional impairment in relation to mental health service utilization were mixed (McKay and Bannon 2004). A more recent meta-analytic review of treatment dropout in child and adolescent outpatient therapy found that 14 child factors predicted treatment dropout, but only one factor (i.e., more contact with deviant peers) demonstrated a medium to large effect size (de Haan et al. 2013). Additionally, ethnic minority status, being diagnosed with an externalizing disorder, and having more externalizing problems consistently predicted treatment dropout across studies, they demonstrated small overall effect sizes. Other factors that predicted treatment dropout included child sex (male), low IQ, poor academic functioning, more psychological diagnoses, referral source, receiving psychotropic medication, and increased levels of parent- and teacher-reported total child problems (de Haan et al. 2013).

Similar child factors have proven to be consistent predictors of treatment engagement as well. For example, a study examining a mostly Latino sample of youth and their families receiving public health services found evidence of lower levels of treatment engagement among Spanish-speaking Latino parents, as compared to English-speaking Latino and NHW parents (Fawley-King et al. 2013). Researchers hypothesize that this finding likely reflects increased barriers to treatment experienced by Spanish-speaking, less acculturated parents of youth with mental health problems. Additionally, parents of children with a medical condition, irrespective of language status, demonstrated higher levels of treatment engagement (Fawley-King et al. 2013).

Conclusions and Future Directions

Better understanding of the contextual factors that impact Latino family participation in youth mental health services is crucial in working to promote improved treatment retention, engagement, and response outcomes. Using a social-ecological framework (Bronfenbrenner 1979), the current review aims to highlight factors and underlying processes that must be considered in working with Latino youth and their families. It is our hope that this empirically supported body of knowledge will help to guide efforts among mental health care providers, administrators, and policy makers to improve mental health services for Latino youth and their families, including helping to inform the development of more culturally responsive treatments. Given that much of the available research has relied on the use of middle-class NHW samples (Flores 2010), results of these studies cannot necessarily be used to explain outcomes for Latino children and their families. However, a growing body of research suggests that various factors across multiple contexts influence Latino family participation in youth mental health services. These variables include perceptions of race/ethnicity and mental health/treatment at the macrosystem (culture) level, access/availability of mental health and community resources at the exosystem (community) level, mental health system and family factors at the microsystem (mental health system and family) level, and parental and child factors at the ontogenetic (individual) level (Bronfenbrenner 1979). As reviewed, cultural and contextual variables may be especially important in working to understand Latino family participation in youth mental health services.

Guided by the current conceptualizations of treatment retention, engagement, and response, as well as the various models that were reviewed, an integrated, conceptual model of the factors that impact Latino family participation in youth mental health is presented in Fig. 1. Not only does this model demonstrate the way in which existing research on treatment retention, engagement, and response is conceptually linked, but it also presents an overview of the contextual factors that impact Latino family participation in youth mental health services from a social-ecological framework (Bronfenbrenner 1979), including numerous contextual variables across multiple levels. This model is intended to help to guide future research and inform efforts to improve mental health services for Latino youth and their families. It is important to note that the specific factors that are outlined were derived from the research that was included in the review and are not meant to be exhaustive. Rather, they are intended to inform current understanding of the specific kinds of variables that impact Latino family participation in youth mental health services.

Fig. 1
figure 1

Conceptual model of Latino family participation in youth mental health services

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According to the research that was reviewed, treatment engagement is considered to be a multidimensional construct that consists of various affective, behavioral, and cognitive components, all of which are thought to impact treatment response (Becker et al. 2015; Haine-Schlagel and Walsh 2015; Staudt 2007). Treatment retention is included as a behavioral indicator of engagement, along with other behavioral indicators of engagement, such as degree/quality of participation, adherence, and progress toward treatment goals. Affective indicators of treatment engagement are thought to include factors such as child/adolescent and/or parent/caregiver emotional investment in treatment, and cognitive indicators may include child/adolescent and/or parent/caregiver attitudes and expectations regarding treatment and motivation. Similar to treatment engagement, treatment response also is considered to be a multidimensional construct and includes various outcomes across multiple domains (Andersen 2008; De Los Reyes and Kazdin 2006; Hoagwood et al. 1996, 2012). These outcomes include child/adolescent symptoms and diagnoses (e.g., perceived and evaluated), parent/caregiver symptoms and diagnoses (e.g., perceived and evaluated), functioning/impairment (e.g., child/adolescent and parent/caregiver), other parent/caregiver and family outcomes (e.g., family relationships and family functioning), consumer perspectives (e.g., child/adolescent and parent/caregiver satisfaction and quality of life), service/system outcomes (e.g., treatment costs and productivity), and other health outcomes (e.g., child/adolescent and parent/caregiver).

According to the conceptual model of Latino family participation in youth mental health services, cultural factors (e.g., perceptions of race/ethnicity, perceptions of mental health/treatment, and SES) and community factors (i.e., access/availability of mental health/community resources, community stressors, and insurance status) function as a medium for Latino family participation in youth mental health services, as opposed to isolated variables of interest. Because mental health system, family, parent/caregiver, and child/adolescent factors may have both direct and indirect effects on treatment response via treatment participation, the conceptual model presents these constructs in this way. It is important to note that the conceptual model also highlights the bidirectional relations between various constructs. For example, just as a therapist’s high level of cultural competency and skills may positive impact client attitudes toward the therapist, negative client attitudes toward a therapist may cause a therapist to experience decreased levels of warmth and empathy toward the client.

Given that the conceptual model is guided by the social-ecological framework (Bronfenbrenner 1979), the model includes various contextual factors across multiple levels. In addition to the cultural and community factors that are outlined above, the conceptual model also includes various mental health system and family and individual factors. Mental health system factors exist at the mental health care organization (e.g., location, access/availability of mental health services, waitlist), therapist (e.g., therapeutic alliance, cultural competence, perceptions of mental health/treatment/client, skills, characteristics, and ethnic matching), and treatment (e.g., modality, treatment demands, cost, cultural congruence, organization, and language) levels. Family and individual factors exist at the family, e.g., sociodemographic variables, functioning, support, and immigration status), parent/caregiver (e.g., sociodemographic, perceptions of mental health treatment/therapist, etiological beliefs, mental health, parental self-efficacy, motivation/satisfaction, ethnic identity, sociocultural values, acculturation, and stress), and child/adolescent (e.g., sociodemographic/diagnostic variables, functioning, sociocultural values, and motivation) levels. Based on the information that was reviewed, these variables are thought to influence Latino family participation in youth mental health services in different ways, such as serving as barriers to treatment or contributing to more favorable retention, engagement, and/or response outcomes. For example, while the location and cost of mental health services have been identified as barriers to mental health treatment for Latino families participating in youth mental health services (Young and Rabiner 2015), improved quality of home and community environments have been linked to improved quality of parental participation in PMT in a sample comprised of families of youth at-risk for conduct problems (Nix et al. 2009).

Although existing research provides a solid foundation of knowledge of factors and processes that affect patterns of mental health care utilization more broadly, there is much to learn about Latino family participation in youth mental health services. Unfortunately, disparities related to the quality and use of mental health services continue to persist, despite Latino youth’s increased risk for developing mental health problems (Gonzales et al. 2009). Not only are Latino individuals less likely than NHWs to receive necessary and adequate mental health services (Zimmerman 2005), but they also are more likely to receive poorer quality of care and drop out of treatment prematurely (Alegría and Woo 2009; Huey 1998; Olfson et al. 2009). Although researchers indicate that traditional mental health services and evidence-based treatments need to be adapted in order to meet the mental health care needs of this growing population (Bernal and Domenech Rodríguez 2009; Bernal et al. 2009a; McCabe et al. 2005), relatively few empirical studies have examined the effects of the various contextual factors that are outlined in Fig. 1 on Latino family participation in youth mental health services. Thus, there is a crucial need to explore these factors, as well as other underlying mechanism of change, in order to facilitate the action that is needed.

The current review highlights various areas in need of additional research. First, given that the child mental health literature has primarily focused on the relation between sociodemographic/diagnostic factors and a limited number of family treatment engagement outcomes (e.g., categories of treatment attendance), future research should aim to expand the current scope of contextual factors and Latino family participation in youth mental health. Specifically, future research should aim to explore the effects of cultural, community, mental health system, family, parent/caregiver, and child/adolescent factors with more diverse samples of Latino youth and their families. Given that the Latino population in the U.S. is highly heterogeneous and includes individuals from various racial/ethnic backgrounds, cultural traditions, and sociopolitical histories (USCB 2012; Ennis et al. 2011; Martinez and Villarruel 2009), it is important that future research aims to include more representative samples of Latino youth and their families in the context of youth mental health services. Additionally, future research should aim to explore the interactions and complex relations that exist between different contextual factors in order to develop a more comprehensive understanding of Latino family participation in mental health services.

In addition to these recommendations, future studies should aim to integrate modern conceptualization of Latino family participation in youth mental health services. For example, given that treatment engagement is considered to be multidimensional construct, future studies should seek to explore influences on the various components of treatment engagement, including other affective, behavioral, and cognitive indicators. Even within the behavioral dimension of treatment engagement, research on treatment retention should integrate modern conceptualization and utilize more of a multimethod, multidimensional assessment of treatment retention. Similarly, future research should aim to examine contextual factors and treatment engagement in relation to the multidimensional construct of treatment response, including the various treatment response outcomes that are presented in Fig. 1. Building on this knowledge, researchers should continue to work to identify, evaluate, and disseminate culturally sensitive, evidence-based interventions and strategies focused on improving the accessibility and quality of mental health services for Latino youth and their families. This includes the continued development of integrated behavioral health services and culturally adapted treatments (Bernal and Domenech Rodríguez 2009; Bridges et al. 2014), both of which may help to address stigmatized mental health attitudes and increased barriers to treatment. Although these methods seek to improve the accessibility and quality of mental health services for Latino youth and their families, future research must strive to continue to identify and improve efforts to reduce existing barriers to mental health care treatment. Incorporating these recommendations into future research is crucial to promoting positive treatment retention, engagement, and response outcomes for Latino youth and their families living in the U.S.