Adapting Pediatric Psychology Interventions: Lessons Learned in
Treating Families From the Middle East
Marisa E. Hilliard,1PHD, Michelle M. Ernst,2,4PHD, Wendy N. Gray,1PHD, Shehzad A. Saeed,3,4MD,
and Sandra Cortina,1,4PHD
1Center for Treatment Adherence, Division of Behavioral Medicine and Clincial Psychology,2Division of
Behavioral Medicine and Clinical Psychology,3Division of Gastroenterology, Hepatology, and Nutrition, and
4Department of Pediatrics, Cincinnati Children’s Hospital Medical Center
All correspondence concerning this article should be addressed to Marisa E. Hilliard, PHD, Center for
Treatment Adherence, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s
Hospital Medical Center, 3333 Burnet Avenue, MLC 7039, Cincinnati, OH 45229, USA.
Received May 18, 2011; revisions received September 9, 2011; accepted September 11, 2011
whose cultures may contrast with a Western medical setting. Research on cultural adaptations of
evidence-based treatments (EBTs), particularly for individuals from the Middle East, is sparse. To address
this need, we discuss clinical issues encountered when working with patients from the Middle East.
Methods Synthesis of the literature regarding culturally adapted EBTs and common themes in Middle
Eastern culture. Case vignettes illustrate possible EBT adaptations.
treatment is an opportunity to join with patients and families to optimize care. Expectations for medical and
psychological treatment vary, and collaborations with cultural liaisons are beneficial.
next steps include systematic development, testing, and training in culturally adapting EBTs in pediatric med-
ical settings. Increased dialogue between clinicians, researchers, and cultural liaisons is needed to share
knowledge and experiences to enhance patient care.
Pediatric psychologists are increasingly called upon to treat children from non-Western countries,
Results Integrating cultural values in
Key words case study; evidence-based practice; professional and training issues.
The population of ethnic minority and immigrant families
in the United States is increasing (Passel & Cohn, 2008),
and people from the Middle East represent one of the
fastest growing groups (Camarota, 2002; Pew Research
Center, 2011). Immigration from this region has occurred
in three waves: in the early 1900s, during the mid to late
twentieth century, and at present in response to war, in-
tensified violence, and political unrest throughout the
Middle East. Many recent immigrants are refugees with
historiesof direct orvicarious
(Hakim-Larson & Nassar-McMillan, 2008) and ongoing
exposure to racial tensions and discrimination (Awad,
Healthcare needs in the Middle East are growing, and
Middle Eastern people are increasingly seeking medical
treatment in other parts of the world (Jamal, 2011). For
example, patients from Middle Eastern countries nearly
quadrupled from 2006 to 2010 at the authors’ institution
(Julie Morin, personal communication, March 23, 2011).
The influx of Middle Easterners in the United States
poses a unique challenge to pediatric psychologists, as
there is little guidance regarding the provision of culturally
relevant care to children and families from this region.
Heterogeneity in religion, values, language, acculturation,
and previous experiences with Western medical settings
can result in differing treatment needs and expectations.
Ethnic identity and the salience of cultural issues vary at dif-
ferent levels of acculturation, even across generations with-
in the same family (Nassar-McMillan & Hakim-Larson,
Journal of Pediatric Psychology 37(8) pp. 882–892, 2012
Advance Access publication October 11, 2011
Journal of Pediatric Psychology vol. 37 no. 8 ? The Author 2011. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: firstname.lastname@example.org
2003). Barriers to providing appropriate treatment exist at
multiple levels, from policy and systems factors that impede
access to care to the availability of culturally relevant thera-
pies (Alegria, Atkins, Farmer, Slaton, & Stelk, 2010;
Gallardo, Johnson, Parham, & Carter, 2009). To our
knowledge, no studies have focused on strategies for de-
livering pediatric psychology treatments at the interface of
Middle Eastern culture with Western medicine.
This article underscores the clinical need for culturally
relevant treatments in pediatric psychology for youth and
families from the Middle East. The aims are to introduce
readers to cultural issues that may impact clinical work
with Middle Eastern children and families with comorbid
medical and psychological or behavioral conditions, and to
discuss potential strategies for treatment adaptations. We
first discuss general perspectives on providing culturally
relevant psychological care. Next, we review terminology,
historical context, and common cultural themes related to
people from the Middle East. In three case vignettes, we
illustrate how cultural issues can impact treatment and pro-
vide examples of treatment adaptation strategies. Finally,
we discuss practical issues and future directions for clinical
care, research, and training.
Providing Culturally Relevant Care
Experts debate the optimal approach to providing cultur-
ally relevant psychological care (Whaley & Davis, 2007).
Supporting the view that evidence-based treatments (EBTs)
should not be modified (Elliott & Mihalic, 2004), some
EBT protocols have demonstrated efficacy for ethnic mi-
nority youths without substantial changes (Kataoka,
Novins, & DeCarlo Santiago, 2010). However, consistent
implementation of EBTs can be difficult even within the
majority culture (Waddell & Godderis, 2005), and some
degree of treatment adaptation is typical. Others advocate
for treatments developed ‘‘bottom-up’’ from specific
cultures’ values and practices (Allwood & Berry, 2006).
When standard EBTs do not have the expected out-
comes and endemic approaches are not feasible, adapta-
tions for particular cultural groups may be made within an
EBT framework (Bernal, Jime ´nez-Chafey, & Domenech
Rodrı ´guez, 2009). This has been described as individual-
ized evidence-based practice in the best interest of patient
care (Whaley & Davis, 2007; Whitley, 2007) and has dem-
onstrated empirical support (Griner & Smith, 2006).
Frameworks for adapting therapies address practical
issues, communication styles, cultural explanations for
symptoms, healing traditions, and acculturation (Lipson
& Meleis, 1983; Sue, Zane, Nagayama Hall, Berger,
2009). Specific strategies include incorporating culturally
salient examples and values, directly addressing issues of
racism, spirituality, and acculturation, involving family
members, and delivering interventions in community set-
tings (Kataoka et al., 2010; Sue et al., 2009). These
approaches are not limited to particular interventions,
and experts agree that such alterations should only be
used to the degree indicated by individual patient needs
(Huey & Polo, 2008; Sue et al., 2009).
Culturally adapted EBTs for mood, anxiety, and sub-
stance abuse disorders have been studied primarily with
Latino and African-American youth and families (Bernal,
2006; Bonner, et al., 2002; Huey & Polo, 2008; Kataoka
et al., 2010; Osuna et al., 2009; Sue et al., 2009). Although
untested, similar adaptation strategies may be beneficial
for youth from the Middle East. The few published case
reports in this population describe psychiatric treatment or
therapy with older adolescents and adults in Middle
Budman, Lipson, & Meleis, 1992; Lipson & Meleis,
1983; Ozerdem, Oguz, Miklowitz, & Cimilli, 2009), but
cases documenting treatment adaptations in pediatric psy-
chology for patients of Middle Eastern descent have not
Terminology and Historical Context
The terms Middle Eastern, Arab, and Muslim are often used
interchangeably, yet refer to distinct geographic areas and
ethnic and religious groups. We use the broadest term,
Middle East, unless otherwise noted. The Middle East is
a geographic region encompassing portions of Northern
Africa, Southwestern Asia, and Europe (Camarota, 2002),
one portion of which includes the 22 Arab League states
(e.g., Syria, Egypt, and Iraq; Al-bab, 2009). An estimated
3.5 million Arab Americans have immigrated to the United
States or trace their family roots to an Arab country (Arab
American Institute, 2011).
Muslims are people who practice the religion of Islam.
Islam is prevalent but not exclusive in the Middle East
and is also practiced in other regions of the world. Arab
Muslims are the fastest growing group of Arab Americans
(Camarota, 2002). Core tenets of Islam include belief in
the providence of Allah; dedication to charity; and worship
that includes daily prayers, fasting during Ramadan, and
making pilgrimage to Makkah (Yosef, 2008). Compared to
other Middle Easterners, Muslims may be more overtly
distinct from mainstream American culture due to religious
practices and attire. Islamic health practices, such as
greater modesty or less inclination to engage in preventive
care, may also diverge from Western and even other Middle
Eastern cultures (Yosef, 2008).
Working With Middle Eastern Families
Particularly since the events of September 11, 2001,
many people of Middle Eastern descent have been sub-
jected to considerable discrimination and intolerance
(Awad 2010; Nassar-McMillan & Hakim-Larson, 2003).
Some Middle Eastern immigrants may have negative feel-
ings about the United States’ foreign policy, while others
may feel positively about the principles of democracy or the
availability of educational and economic resources (Arab
American Institute, 2009). There is also substantial vari-
ability in opinions about the Middle East within the United
States (Pew Research Center for People & the Press, 2011).
Middle Eastern Culture and Western Models
The case vignettes that follow illustrate how features of
Middle Eastern culture can interface with pediatric psycho-
logical treatment in a Western medical setting. We describe
each patient’s presentation, relevant cultural themes, and
how the therapist adapted treatment based on cultural fac-
tors (Table I). While each case illustrates unique issues,
they share common features. The referrals to psychology
were made by medical teams who were becoming increas-
ingly frustrated with slow progress or behavioral issues in-
terfering with medical care. This frustration reflected
mismatched expectations of the families, therapists, and
medical teams. Each therapist attempted to deliver a pedi-
atric psychology EBT based on symptom presentation, sub-
sequently recognized that cultural issues were impacting
treatment, and adapted the intervention approach. Each
case demonstrates how cultural issues that may initially
be seen as treatment barriers can be conceptualized as
strengths or resources and used to personalize and support
therapy (Table I). Per institutional policies, the clinical
cases described here did not qualify as human subjects
research and did not require IRB review.
Two common themes of Middle Eastern culture in the
case vignettes were medical and mental health beliefs and
family structure and hierarchies.
Medical Beliefs and Practices
Western medical practices may contrast with the health-
related beliefs and expectations of some Middle Eastern
cultures (Kulwicki et al., 2000). Given their high regard
for Western medicine, many Middle Easterners expect ex-
pertise and effectiveness (Meleis, 1981). For example,
some parents may insist their child to be treated by the pro-
vider with the highest status, rank, or education (Lipson &
Meleis, 1983; Meleis, 1981; Zahr & Hattar-Pollara, 1998),
which some providers might perceive as demanding. While
a thorough assessment of history and symptoms is typical
in Western medical settings, some Middle Eastern patients
may be uncomfortable sharing such private information
outside of the family (Nassar-McMillan & Hakim-Larson,
2003), yet expect accurate diagnosis and effective treat-
ment (Lipson & Meleis, 1983; Meleis, 1981; Yosef,
2008). Contrasting with Western models of patient-
centered care that emphasize shared decision making be-
tween the patient and provider, obtaining patient input or
discussions about treatment options may be perceived as a
lack of expertise or authority (Al-Krenawi & Graham,
2000; Meleis, 1981). Furthermore, it is often extended
families, rather than medical providers, that share health
information with the patient (Kulwicki et al., 2000; Yosef,
Traditional Middle Eastern beliefs about illness may
also differ from Western beliefs. While the biomedical
foundations of Western medicine are generally respected
(Meleis, 1981), some Middle Easterners may also attribute
symptoms to spiritual causes and use folk healers with or
without the knowledge of the medical team (Al-Krenawi &
Graham, 2000; Zahr & Hattar-Pollara, 1998). Individuals
with less experience in medical settings may be unaccus-
tomed to medical terminology and may use nonspecific
terms or metaphors to describe symptoms (Al-Krenawi &
Graham, 2000; Zahr & Hattar-Pollara, 1998). In addition,
some Western providers that value individual proactivity
may perceive Muslims as passive or fatalistic due to the
Islamic belief that illness and healing are at the will of Allah
(e.g., ‘‘In-sha-allah’’ or ‘‘god-willing’’; Lipson & Meleis,
1983; Zahr & Hattar-Pollara, 1998).
Mental Health Beliefs
Given the stigma around mental illness (Al-Krenawi &
Graham, 2000; Youssef & Deane, 2006), psychological
symptoms can be manifested somatically or be interpreted
as a medical issue (Hakim-Larson & Nassar-McMillan,
2008; Zahr & Hatar-Pollara, 1998). Some Middle Eastern
patients may therefore expect to undergo a medical proce-
dure or be prescribed medication (Al-Krenawi & Graham,
2000; Lipson & Meleis, 1983), and be less interested in
behavioral treatments. The emphasis on individual asser-
tiveness and behavior change in cognitive-behavioral
therapy, a mainstay of pediatric psychology, may be
particularly discordant with cultural values (Dwairy &
Van Sickle, 1996).
Family Structure and Hierarchies
The family unit, including extended family, tends to be
valued over the individual, and solutions are often sought
from within the family before turning to external supports
Hilliard et al.
(Dwairy & Achoui, 2006; Hakim-Larson & Nassar-
McMillan, 2008). Traditional gender roles are common
(Hakim-Larson & Nassar-McMillan, 2008), and the family
patriarch may be the gatekeeper of private information and
make health-related decisions for the patient (Lipson &
Meleis, 1983; Zahr & Hattar-Pollara, 1998).
The following case vignettes illustrate these and other
common cultural issues in treating youth and families
from the Middle East. The therapists were licensed clinical
psychologists, supervised predoctoral interns, or postdoc-
toral fellowswith specializedtrainingin pediatric
Table I. Common Cultural Themes and Potential Treatment Adaptations
Theme Possible presentationStrengths Potential EBT adaptations
experts to treat
Family investment in
obtaining the best
available care, respect
for Western medicine
Conceptualize psychological problems within a medical framework to
Elicit family beliefs, expectations, and goals for treatment
Clearly discuss treatment plans (e.g., approach, rationale, anticipated
number of sessions, and how to measure progress) prior to delivering
care and throughout treatment
Adopt a directive rather than collaborative style to minimize concerns
regarding therapist expertise or authority
Seek input from the head of family (most often a male) regarding
treatment presentation and progress (including subjective ratings of
Routinely discuss outcomes and plans with family leader
Elicit information on gender norms and expectations
If possible for females, match therapist and patient gender
Clarify the family structure. Identify and include all individuals involved
Discuss family values regarding parenting practices and help the family
establish behavior plans in line with beliefs
Emphasize family’s role in helping the child resolve difficulties
Consult with community members/cultural liaisons to understand impact
of religious beliefs and answer questions about religious practices
If Muslim, consider referencing to Allah for support in making changes
and overcoming adversity
sons vs. daughters,
preference for male
Clear structure for
Support of multiple family
members, opportunity to
get input from several
Religion Limitations on
procedures due to
possibly in other
Faith as a means of coping,
opportunity to join with
religious leaders in
Emphasis on history of
survival and coping with
difficult situations as a
source of strength
Assess and address in therapy as needed, with expectation that
assessment may be difficult until rapport is slowly established
Make referrals for family members to the degree of their comfort
Interpreters and cultural
liaisons can provide a
family relationship with
interpreter can be a source
of social support or
connection with the
Opportunity to draw on
traditions or comforts
(e.g., foods and music)
from home country as a
source of coping
Consult with interpreters prior to session to orient them to psychological
treatment, debrief after
Clarify therapist expectations for the interpreter’s role, including level
and amount of translation. Is paraphrasing allowed? Who explains or
clarifies patient questions? Is all conversation translated or can some
be private? When possible, request interpreters familiar with
psychology or that the provider has worked with before.
Involve social work for assistance obtaining needed resources (financial,
logistical, religious, and social)
Access programs within the medical center or community to engage
families (e.g., through pastoral care or local Islamic centers)
Working With Middle Eastern Families
psychology. They were all Caucasian or Hispanic women.
The disposition of each case was determined by the ther-
apist and referring medical provider(s).
‘‘Faisal’’ was a preadolescent male with a blood disorder
requiring frequent blood draws, injections, and transfu-
sions. He was referred for needle phobia in anticipation
of an upcoming inpatient hospitalization. The selected
EBT was systematic desensitization and in vivo exposure
(O¨st, Hellstro ¨m, & Ka ˚ver, 1992; Rainwater et al., 1988).
Treatment consisted of eight outpatient sessions. Faisal’s
case illustrates the cross-cutting themes of family patriar-
chy and expectations for mental health treatment, and an
example of how refugee experiences played into therapy.
Faisal’s father was the primary informant regarding Faisal’s
symptoms and history, and Faisal’s participation in therapy
depended upon his father’s beliefs about treatment effica-
cy. Initially, it was difficult to obtain subjective ratings of
distress from Faisal, and his father expressed dissatisfac-
tion with the therapist relying on Faisal’s self-report. He
observed that Faisal was providing underestimates of his
distress, possibly due to cultural norms around privacy
(Nassar-McMillan & Hakim-Larson, 2003). In order to
obtain paternal ‘‘buy in’’ and respect his status in the
family, the therapist subsequently addressed Faisal’s
father first and involved him in all aspects of treatment
(Youssef & Deane, 2006; Zahr & Hattar-Pollara, 1998).
Faisal’s father met regularly with the therapist to discuss
perceptions of treatment progress and provide suggestions.
For example, the therapist asked him to help create the
exposure hierarchy and to provide his own ratings of
Faisal’s distress during exposure exercises, which was
used in conjunction with Faisal’s self-report and the ther-
apist’s proxy ratings of distress (e.g., heart rate).
Mental Health Beliefs
At intake, Faisal’s parents expressed their belief that
Faisal’s needle phobia was a medical, not psychological,
problem. This impacted their expectations for treatment.
Faisal’s father voiced frustration with perceived limited
progress despite multiple treatment sessions, which at
that time had included a diagnostic interview, one session
of relaxation training, and one session of psychoeducation
and fear hierarchy creation. In order to align the therapist’s
and family’s expectations for therapy and link the behav-
ioral treatment plan with Faisal’s somatic symptoms,
the therapist provided additional education, empirical
support, and rationale for treatment. She emphasized the
physiological aspects of anxiety (i.e., autonomic arousal)
and the expectation that repeated exposure to the feared
stimulus (i.e., procedures with needles) would decrease
Faisal’s conditioned response and improve his coping.
Based on empirical support for consolidated exposure ses-
sions (Zlomke & Davis, 2008), weekly hour-long treatment
sessions were replaced with twice-weekly 2-hr sessions.
In vivo exposures were conducted in medical clinic space
with Faisal’s nurses to enhance the relevance of the treat-
ment to his medical care. To help the family recognize
treatment progress, the therapist also highlighted evidence
of reduced distress during exposure exercises to and rou-
tinely communicated to the family reports from medical
team about decreases in resistance and time needed for
Among Middle Eastern immigrants, exposure to wartime
trauma and persecution has been linked with poor psycho-
logical adjustment (Keyes, 2000) and high rates of mood
disorders and post-traumatic stress disorder (Cardozo
et al., 2004). Parents and children with refugee status are
at particular risk (Hosin, 2005; Montgomery, 2010), which
may interfere with their ability to cope with medical stress-
ors (Nassar-McMillan & Hakim-Larson, 2003). In Faisal’s
case, the therapist observed the family using coping strat-
egies that appeared to heighten rather than ameliorate
Faisal’s anxiety reaction, such as crying, yelling, and coerc-
ing him during medical procedures. Given that Faisal’s
family had refugee status, the therapist recognized how
his parents’ prior coping strategies for refugee-related
stressors may have generalized to difficulties coping with
Faisal’s needle phobia. She thus assessed their emotional
states to determine their ability to manage their worries
about Faisal’s health and endure the initial difficulty of
exposure therapy. Despite initial reluctance, as rapport
grew, Faisal’s father described his experiences coping
with refugee-related challenges and current difficulties
with social isolation, discrimination, and limited financial
resources. By processing these stressors, the family gained
emotional strength to face the difficulties of Faisal’s illness
and support him during treatment.
The cultural adaptations made to Faisal’s case enhanced
treatment progress and resulted in a significant decrease in
his fear around medical procedures. Faisal and his father
reported only minimal distress prior to subsequent blood
draws and injections, and the medical team reported no
difficulties during his inpatient hospitalization. Respecting
the family’s patriarchal structure and grounding behavioral
Hilliard et al.
therapy in an empirical medical context enhanced rapport
and increased the family’s confidence and engagement in
treatment. Processing refugee-related stressors also benefit-
ted Faisal by addressing his parents’ distress and enhanc-
ing their ability to provide him support.
‘‘Nadia’’ was an adolescent female treated on an inpatient
medical unit for anorexia following an unsuccessful course
of outpatient therapy (e.g., attempts to disguise weight
loss, inability to gain or maintain weight). Her inpatient
treatment followed a standard EBT protocol for anorexia,
including prescribed caloric intake, restriction from
exercise, contingency management, and family therapy
(American Psychiatric Association, 2006). She received four
sessions with a therapist as part of the protocol. This case
illustrates two themes of Middle Eastern culture, religious
practices, and traditional gender roles, in a family with
different levels of acculturation across generations.
Muslim faith requires multiple daily prayers that involve
repeatedly moving from standing to a prostrate position.
Nadia’s family encouraged her to observe religious practice.
While Nadia initially only read religious texts in her room,
her nurses communicated concern about her increasing
use of physically active prayer on the medical floor as a
potential source of exercise and a possible barrier to treat-
ment. The therapist discussed this potential treatment bar-
rier with Nadia’s family, who was uncomfortable limiting
her involvement in prayer. In order to learn more about
Islamic religious beliefs and prayer practices in this con-
text, her therapist consulted with a female Muslim physi-
cian at the hospital and an imam, a religious leader in the
regarding an exemption from prayer for individuals with
a medical condition and increased the family’s acceptance
of prayer without the typical physical exertion.
Nadia and her older brother were the first generation born
in the United States and their parents had distinct expec-
tations for them based on their genders (Hakim-Larson &
Nassar-McMillan, 2008). Nadia’s brother was strongly en-
couraged to attend college and was allowed considerable
social freedom, while she was expected to help with the
home and family business. In order to consider how these
issues played into Nadia’s symptoms, the therapist encour-
aged Nadia to process the contrasts between Islamic expec-
tations for females and American culture with the imam.
Through this process, it became evident that Nadia felt
more socially limited than her brother and peers, and
that she was attempting to gain control by restricting her
diet and engaging in exercise. To promote shared decision
making and foster a reconnection between Nadia and her
family, the therapist included Nadia’s parents and brother
in therapy. This also ensured that family values were
respected during the process of developing strategies to
enhance Nadia’s sense of freedom (e.g., Nadia’s brother
chaperoned her in social settings).
With treatment informed by cultural factors, Nadia suc-
cessfully gained weight during her inpatient admission
and transitioned to an outpatient therapist. Consultation
with experts in Islam allowed the therapist to learn about
prayer practices, build trust, and ultimately provide effec-
tive treatment in the context of the family’s religious and
cultural background. The imam provided valuable normal-
ization of religious struggles and assuaged the family’s con-
cerns about refraining from physically active prayer during
her hospitalization. By addressing gender issues, Nadia and
her brother generated ideas to increase her social interac-
tions in ways that were acceptable to her family.
‘‘Salma’’ was a young girl temporarily in the United States
to receive cancer treatment. Inpatient psychology was con-
sulted to address uncooperative behaviors compromising
medical care on both the part of Salma (e.g., refusing to
take her medication) and her family (e.g., parents allowing
Salma to refuse her medication or not having Salma ready
for therapies). Treatment involved eight consultation ses-
sions focusing on implementation of evidence-based be-
havioral strategies to increase adherence, such as parent
behavior management training, establishing daily routines,
and developing a behavioral plan to enhance cooperation
with medication and procedures (Kahana, Drotar, &
Frazier, 2008). This case is an example of Middle Eastern
family and parenting practices.
Collectivist Family Structure
Due to illness in Salma’s father, her mother was the head of
household and was supported by extended family mem-
bers. The therapist sought their opinions about Salma and
included them in treatment when they were present. Salma
and her family typically returned from day passes much
later than expected, which interfered with the medical
team’s schedule for medication administration. Salma’s
mother expressed that spending time with the family was
more important to her than following the hospital’s sched-
ule, yet the team was frustrated and felt that it was wrong
Working With Middle Eastern Families
for Salma to be out so late at night. Recognizing this as an
important cultural issue, the therapist educated the team
about cultural norms and worked with the family to un-
derstand the practicalities of a busy nursing staff. In order
to allow maximum time with the family while meeting
Salma’s medical and rehabilitative needs, the therapist
worked with the family and staff to develop effective and
realistic schedules for medication and therapies (e.g.,
shifted later in the evening).
In some Middle Eastern families, strict child control is seen
as necessary to preserve family dynamics and roles, consis-
tent with a higher rate of authoritarian parenting practices
(Baumrind, 1967) than is typical in Western cultures
(Dwairy & Achoui, 2010). Three unique parenting styles
have been observed in this population: controlling (com-
bines Baumrind’s authoritarian and authoritative styles),
flexible (combines authoritative and permissive), and in-
consistent (combines authoritative and permissive). The
controlling and flexible styles are typically seen as positive
in Middle Eastern cultures, and only inconsistent parenting
has demonstrated negative implications for child develop-
ment in this group (Dwairy, 2008). In order to engage
Salma’s family in behavior management, the therapist pro-
vided education about behavioral reinforcement to all
family members, modeled providing praise, and introduced
a behavioral chart. However, the family resisted these in-
terventions because they were not consistent with their
permissive (e.g., resisted setting firm behavioral expecta-
tions around medical procedures or meals) and authoritar-
ian (e.g., uncomfortable providing praise for engaging in
procedures; punishment for using the bedpan rather than
toilet) parenting approaches. The family acknowledged that
behavioral charts were useful for increasing Salma’s partic-
ipation in therapies and meals and for decreasing out-
bursts, but preferred that staff rather than family provide
reinforcers and consequences. The therapist therefore
utilized the nursing staff to be the agents of Salma’s
behavior change and worked with Salma’s family to identify
culturally appropriate forms of praise, such as increased
warmth and attention rather than verbal or tangible
By recognizing the importance of spending time with
family, the team adapted Salma’s medical and nonmedical
therapy routines to be more flexible and consistent with
the family’s schedule, and her adherence to medication
administration and participation in therapies increased.
Similarly, behavior management became more effective
when the therapist considered Salma’s mother’s parenting
behaviors from a cultural perspective. However, despite
improvements when staff oversaw behavior management,
the absence of consistent limit-setting and reinforcement
from the family resulted in Salma successfully avoiding
some aversive yet necessary medical care. These challenges
may be due to a discrepancy between the inconsistent par-
enting style of Salma’s family and the emphasis on author-
management training. They may also reflect a cultural def-
erence to experts in addressing and remedying health and
& Graham, 2000;
There is an urgent need for culturally relevant provision of
EBTs in pediatric psychology, particularly for children and
families from the Middle East. The influx of immigrants,
recent political unrest, ongoing exposure to violence and
discrimination, and anticipated medical and mental health
needs of Middle Easterners in the United States call for
more clinical and empirical attention. Pediatric psycholo-
gists have the opportunity to liaison with our medical col-
leagues regarding the intersection of culture with medical
care. Increased research and clinical training with this pop-
ulation is a critical next step. Opportunities for researchers
and clinicians to share their experiences will be valuable to
increase awareness and prompt dialogue regarding strate-
gies for culturally relevant care.
The typical biopsychosocial approach to pediatric psy-
chological care encompasses all of the relevant themes to
working with Middle Eastern families discussed in this
paper, including considering parenting practices and
family structure, being aware of communication styles,
and assessing for trauma exposure (Roberts & Steele,
2009). However, as providers we must challenge our as-
sumptions on an individual and family level. Despite
common themes, there is great heterogeneity, and individ-
ual assessment and case conceptualization incorporating
relevant cultural issues are crucial to appropriately and
effectively tailor treatment. While general awareness of
cultural themes is a good starting point, ongoing evaluation
of specific family and individual norms, values, and beliefs
is necessary for appropriate treatment planning and inter-
The three case vignettes presented in this article high-
light the similarities and heterogeneity of pediatric patients
from the Middle East and their families. Through these
cases and in Table I, we provided examples of how cultural
themes may emerge in treatment, how they can be
Hilliard et al.
understood as resources rather than barriers to care, and
culturally relevant approaches to adapting treatment.
Commonalities include the importance of family and
desire for the best possible care from the most qualified
providers, consistent with the broader literature regarding
Middle Eastern patients and families. While the patriarchy
of Faisal and Nadia’s families contrasted with the matriar-
chy and extended family network in Salma’s family, the
centrality of close family relationships and parents’ concern
for their children’s health and recovery was pivotal in all
cases. Each case also involved addressing family’s expecta-
tions about provider expertise. For example, Faisal’s father
expressed frustration with the therapy process and rate of
improvement in order to advocate for Faisal to receive the
best care, although this may have initially disrupted rap-
port building and created defensiveness in the therapist.
Efforts to demonstrate expertise included emphasizing data
regarding progress and receiving support from the medical
Cultural factors that may be initially perceived as bar-
riers to treatment may be better understood as opportuni-
ties for enhanced, personalized treatment. For example, the
paternal role of family advocate in Faisal’s case, the impor-
tance of extended family members in Salma’s case, and the
role of prayer and faith in Nadia’s case were originally seen
as major challenges to providing evidence-based care. The
therapists faced difficult decisions in whether, to what
degree, and how to deviate from EBT protocols in the con-
text of these factors. However, by viewing these cultural
issues as strengths, these perceived barriers were incorpo-
rated into treatment and ultimately benefitted care. The
therapists were able to join with the children and families
to work toward common goals in a manner that was
acceptable and appropriate. On an individual level, pediat-
ric psychologists may be challenged to adapt their thera-
peutic approach or style to meet the needs and cultural
contexts of their patients and families. This approach to
true family- or patient-centered care has strong potential to
improve treatment outcomes.
While some patients may benefit from standard care
with no cultural adaptations (Kataoka et al., 2010), treat-
ment adaptations can be beneficial in many cases (Griner
& Smith, 2006). Developing and using culturally based
therapeutic approaches (i.e., ‘‘bottom-up’’ or endemic
approaches; Allwood & Berry, 2006; Kataoka et al.,
2010) may be especially useful with particular cultural
groups. Another treatment factor to consider is the
‘‘mismatch’’ of patient and provider ethnicity in these
cases. The therapists were not of Middle Eastern descent,
which could have impacted the therapeutic relationship.
However, evidence for this is equivocal (Karlsson, 2005),
and the collaboration with cultural liaisons of similar back-
grounds may have minimized this risk.
Given the current lack of empirical guidance, providers
must often be creative in assessing and integrating cultural
issues into therapy and must consider practical challenges,
such as how to gather cultural information and communi-
cate effectively. A primary challenge is assessing which as-
pects of the child’s presentation reflect illness symptoms
versus individual, family, or cultural characteristics. In line
with Ecological Systems Theory (Bronfenbrenner, 1979),
factors on each of these levels likely influence patient pre-
sentation. In addition to literature about cultural norms,
therapists are encouraged to use their own clinical obser-
vations and those made by nurses and other medical pro-
viders. For example, the concerns Nadia’s nurses initially
raised about her physically active prayer ultimately benefit-
ted her treatment success. Although rapport can initially be
slow to develop (Al-Krenawi & Graham, 2000; Dwairy &
Van Sickle, 1996), asking respectful questions can also
garner valuable information about health beliefs, expecta-
tions for treatment, and sources of support. For example,
after discussing family values with Salma’s mother, the
focus of conversation with the medical team changed
from ‘‘bad parenting’’ to exploring modifications to routine
Differences in language and communication style,
including volume and tone of speech, gesticulation, eye
contact, and distance between speakers (Dwairy & Van
Sickle, 1996; Hakim-Larson & Nassar-McMillan, 2008),
are commonly cited as barriers to care for people from
the Middle East in Western medical settings (Kulwicki
et al., 2000; Nassar-McMillan & Hakim-Larson, 2003).
Language interpreters can be helpful for nonnative
English speakers. However, interpreters can affect rapport,
and some may inadvertently paraphrase, omit therapist
comments or directives, or minimize or exaggerate symp-
toms (Miller, Martell, Pazdirek, Caruth, & Lopez, 2005). In
Salma’s case, the family became close with one interpreter
and frequently had peripheral conversation in Arabic that
interfered with therapy. Therapists and interpreters are
urged to discuss expectations for the interpreters’ role in
treatment (Searight & Searight, 2009).
Therapists are encouraged to consult with cultural bro-
kers or liaisons to increase their awareness of relevant cul-
tural factors and enhance communication (Al-Krenawi &
Graham, 2000). Interpreters can serve this role by sharing
cultural insights about patients’ behavior (Dysart-Gale,
2007; Miller et al., 2005; Searight & Searight, 2009). For
example, Faisal’s therapist regularly consulted with the in-
terpreter for a cultural perspective on the family’s behavior
in session, coping, and ‘‘buy in’’ to the therapy process,
Working With Middle Eastern Families
which enhanced rapport and generated ideas for treatment
adaptations. In Nadia’s case, consultation with two cultur-
al liaisons was a critical piece of her care.
Increased cultural awareness in pediatric psychology
has implications for the translation of clinical research. The
challenge of providing culturally relevant care is not unique
to treating families from the Middle East. Because EBT
protocols are typically not developed in the ‘‘real world,’’
problems with translating from research to practice set-
tings are inevitable (Waddell & Godderis, 2005). This is
especially relevant whenever patients present from diverse
backgrounds, or with complex medical histories or psy-
chological comorbidities (i.e., when real patients deviate
from the standard research sample). More systematic
development and testing of culturally relevant EBT adap-
tations in pediatric medical settings are needed to facili-
tate the process of translating treatments from research
to practice for patients from ethnic minority groups.
There is a range of scientific approaches to implement
and examine cultural adaptations of EBTs, including case
series, quality improvement approaches, or clinical trials.
The themes and strategies reviewed in this paper are
specific to children and families from the Middle East,
yet may be generalizable in principle to other cultural
Finally, clinical training should involve practical expe-
riences in making adaptations to evidence-based treatment
strategies based on individual and family culture. While the
development of culturally relevant interventions for every
ethnic group and symptom presentation is not practical,
supervised experience in making educated deviations from
EBT protocols are possible and could increase confidence
and competence in working with diverse families.
Illustrative cases, like those presented here, may be of par-
ticular value in this endeavor (Stewart & Chambless,
2010). Awareness of one’s own biases and assumptions
is a vital first step toward ethical practice with any patient
or family and may be especially helpful to pediatric psy-
chologists working with families from the Middle East in
the post 9/11 era.
Conflicts of interest: None declared.
Al-bab. (2009). The league of Arab states. Retrieved from
Al-Krenawi, A. (1998). Family therapy with a
multiparental/multispousal family. Family Process, 37,
Al-Krenawi, A., & Graham, J. R. (2000). Culturally sensitive
social work practice with Arab clients in mental
health settings. Health & Social Work, 25, 9–22.
Alegria, M., Atkins, M., Farmer, E., Slaton, E., &
Stelk, W. (2010). One size does not fit all: Taking di-
versity, culture and context seriously. Administration
and Policy in Mental Health, 37, 48–60.
Allwood, C. M., & Berry, J. W. (2006). Origins and de-
velopment of indigenous psychologies: An interna-
tional analysis. International Journal of Psychology, 41,
American Psychiatric Association. (2006). American
Psychiatric Association practice guidelines for the treat-
ment of psychiatric disorders: Compendium 2006.
Retrieved from http://www.psychiatryonline.com/con-
Arab American Institute. (2009). The 2009 Arab public
opinion poll: A view from the Middle East. Retrieved
Arab American Institute. (2011). Arab Americans.
Retrieved from http://www.aaiusa.org/pages/
Awad, G. H. (2010). The impact of acculturation and re-
ligious identification on perceived discrimination for
Arab/Middle Eastern Americans. Cultural Diversity
and Ethnic Minority Psychology, 16, 59–67.
Baumrind, D. (1967). Child care practices anteceding
three patterns of preschool behavior. Genetic
Psychology Monographs, 75, 43–88.
Bernal, G. (2006). Intervention development and cultural
adaptation research with diverse families. Family
Process, 45, 143–151.
Bernal, G., Jime ´nez-Chafey, M. I., & Domenech
Rodrı ´guez, M. M. (2009). Cultural adaptation of
treatments: A resource for considering culture in
evidence-based practice. Professional Psychology:
Research and Practice, 40, 361–368.
Bonner, S., Zimmerman, B. J., Evans, D., Irigoyen, M.,
Resnick, D., & Mellins, R. B. (2002). An individual-
ized intervention to improve asthma management
among urban Latino and African-American families.
Journal of Asthma, 39, 167–179.
Bronfenbrenner, U. (1979). The ecology of human develop-
ment: Experiments by nature and design. Cambridge,
MA: Harvard University Press.
Budman, C. L., Lipson, J. G., & Meleis, A. I. (1992).
The cultural consultant in mental health care:
The case of an Arab adolescent. American Journal of
Orthopsychiatry, 62, 359–370.
Hilliard et al.
Camarota, S. A. (2002). Immigrants from the Middle East:
A profile of the foreign-born population from Pakistan
to Morocco. Retrieved from http://www.cis.org/arti-
Cardozo, B. L., Bilukha, O. O., Crawford, C. A.,
Shaikh, I., Wolfe, M. I., Gerber, M. L., &
Anderson, M. (2004). Mental health, social
functioning, and disability in postwar Afghanistan.
Journal of the American Medical Association, 292,
Dwairy, M. (2008). Parental inconsistency versus parental
authoritarianism: Associations with symptoms of psy-
chological disorders. Journal of Youth and Adolescence,
Dwairy, M., & Achoui, M. (2006). Introduction to three
cross-regional research studies on parenting styles,
individuation, and mental health in Arab societies.
Journal of Cross-Cultural Psychology, 37, 221–229.
Dwairy, M., & Achoui, M. (2010). Parental control: A
second cross-cultural research on parenting and psy-
chological adjustment of children. Journal of Child
and Family Studies, 19, 16–22.
Dwairy, M., & Van Sickle, T. D. (1996). Western psycho-
therapy in traditional Arabic societies. Clinical
Psychology Review, 16, 231–249.
Dysart-Gale, D. (2007). Clinicians and medical interpret-
ers: Negotiating culturally appropriate care for pa-
tients with limited English ability. Family and
Community Health, 30, 237–246.
Elliott, D. S., & Mihalic, S. (2004). Issues in disseminat-
ing and replicating effective prevention programs.
Prevention Science, 5, 47–53.
Gallardo, M. E., Johnson, J., Parham, T. A., &
Carter, J. A. (2009). Ethics and multiculturalism:
Advancing cultural and clinical responsiveness.
Professional Psychology: Research and Practice, 40,
Griner, D., & Smith, T.B. (2006). Culturally adapted
mental health interventions: A meta-analytic review.
Psychotherapy: Theory, research, practice, training, 43,
Hakim-Larson, J., & Nassar-McMillan, S. (2008). Middle
Eastern Americans. In G. J. McAuliffe (Ed.),
Culturally alert counseling: A comprehensive introduc-
tion (pp 293–322). Thousand Oaks, CA: Sage
Hosin, A. A., Moore, S., & Gaitanou, C. (2005). The
relationship between psychological well-being and
adjustment of both parents and children of exile and
traumatized Iraqi refugees. Journal of Muslim Mental
Health, 1, 123–136.
Huey, S. J., & Polo, A. J. (2008). Evidence-based psycho-
social treatments for ethnic minority youth. Journal
of Clinical Child and Adolescent Psychology, 37,
Jamal (2011). Mideast government spends $7.5 bn on
overseas treatment. Medical Tourism Magazine.
Retrieved from http://www.medicaltourismmag.com/
Kahana, S., Drotar, D., & Frazier, T. (2008). Meta-analysis
of psychological interventions to promote adherence
to treatment in pediatric chronic health conditions.
Journal of Pediatric Psychology, 33, 590–611.
Karlsson, R. (2005). Ethnic matching between therapist
and patient in psychotherapy: An overview of find-
ings, together with methodological and conceptual
issues. Cultural Diversity and Ethnic Minority
Psychology, 11, 113–129.
Kataoka, S., Novins, D. K., & DeCarlo Santiago, C.
(2010). The practice of evidence-based treat-
ments in ethnic minority youth. Child and
Adolescent Psychiatric Clinics of North America, 19,
Keyes, E. F. (2000). Mental health status in refugees: An
integrative review of current research. Issues in
Mental Health Nursing, 21, 397–410.
Kulwicki, A. D., Miller, J., & Schim, S. M. (2000).
Collaborative partnership for cultural care:
Enhancing health services for the Arab
community. Journal of Transcultural Nursing, 11,
Lipson, J. G., & Meleis, A. I. (1983). Issues in health
care of Middle Eastern patients. The Western Journal
of Medicine, 139, 854–861.
Meleis, A. I. (1981). The Arab American in the health
care system. American Journal of Nursing, 81,
Miller, K. E., Martell, Z. L., Pazdirek, L., Caruth, M., &
Lopez, D. (2005). The role of interpreters
in psychotherapy with refugees: An exploratory
study. American Journal of Orthopsychiatry, 75,
Montgomery, E. (2010). Trauma and resilience in young
refugees: A 9-year follow-up study. Developmental
Psychopathology, 22, 477–489.
Nassar-McMillan, S. C., & Hakim-Larson, J. (2003).
Counseling considerations among Arab Americans.
Journal of Counseling and Development, 81, 150–159.
O¨st, L., Hellstro ¨m, K., & Ka ˚ver, A. (1992). One versus
five sessions of exposure in the treatment of injection
phobia. Behavior Therapy, 23, 163–282.
Working With Middle Eastern Families
Osuna, D., Barrera, M., Strycker, L. A., Toobert, D. J., Download full-text
Glasgow, R. E., Geno, C. R., ... Doty, A. T.
(2009). Methods for the cultural adaptation of a
diabetes lifestyle intervention for Latinas: An illus-
trative project. Health Promotion Practice, 12,
Ozerdem, A., Oguz, M., Miklowitz, D., & Cimilli, C.
(2009). Family focused treatment for patients with
bipolar disorder in Turkey: A case series. Family
Process, 48, 417–428.
Passel, J. S., & Cohn, D. (2008). U.S. population projec-
tions: 2005-2050. Retrieved from http://pewhispanic.
Pew Research Center. (2011). The future of the global
Muslim population. Retrieved from http://pewforum.
Pew Research Center for People & the Press. (2011).
Views of Middle East unchanged by recent events:
Public remains wary of global engagement. Retrieved
Rainwater, N., Sweet, A. A., Elliott, L., Bowers, M.,
McNeill, J., & Stump, N. (1988). Systematic desensi-
tization in the treatment of needle phobias in chil-
dren with diabetes. Child & Family Behavior Therapy,
Roberts, M. C., & Steele, R. G. (2009). Handbook
of pediatric psychology. New York: The Guilford Press.
Searight, H. R., & Searight, B. K. (2009).
Working with foreign language interpreters:
Recommendations for psychological practice.
Professional Psychology: Research and Practice, 40,
Stewart, R. E., & Chambless, D. L. Interesting practition-
ers in training in empirically supported treatments:
Research review versus case studies. Journal of
Clinical Psychology, 66, 73–95.
Sue, S., Zane, N., Nagayama Hall, G. C., & Berger, L. K.
(2009). The case for cultural competency in psycho-
therapeutic interventions. Annual Review of
Psychology, 60, 525–548.
Waddell, C., & Godderis, R. (2005). Rethinking
evidence-based practice for children’s mental health.
Evidence-Based Mental Health, 8, 60–62.
Whaley, A. L., & Davis, K. E. (2007). Cultural compe-
tence and evidence-based practice in mental health
services: A complementary perspective. American
Psychologist, 62, 563–574.
Whitley, R. (2007). Cultural competence, evidence-based
medicine, and evidence-based practices. Psychiatric
Services, 58, 1588–1590.
Yosef, A. R. O. (2008). Health beliefs, practice, and prior-
ities for health care of Arab Muslims in the United
States: Implications for nursing care. Journal of
Transcultural Nursing, 19, 284–291.
Youssef, J., & Deane, F. P. (2006). Factors influencing
mental-health help-seeking in Arabic-speaking com-
munities in Sydney, Australia. Mental Health, Religion
& Culture, 9, 43–66.
Zahr, L. K., & Hattar-Pollara, M. (1998). Nursing care of
Arab children: Consideration of cultural factors.
Journal of Pediatric Nursing, 13, 349–355.
Zlomke, K., & Davis, T. E. (2008). One-session treatment
of specific phobias: A detailed description and
review of treatment efficacy. Behavior Therapy, 39,
Hilliard et al.