Culturally competent systems of care for children's mental health: advances and challenges.
ABSTRACT There has been a remarkable growth in cultural diversity in the United States over the past 20 years. The population of minority groups has increased at a much faster rate than the European-background population in America, and faster even among children and youth. At the same time, minority youth face increasing disparities in their mental health and in access to mental health services. These are related to the multiple challenges they already face in socioeconomic status, but are aggravated by the lack of culturally competent services that can address their specific mental health needs within the context of their culture, family, and community. This paper reviews the current knowledge about the mental health of culturally diverse youth in the United States, and provides guidance on approaches to address the disparities they face.
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ABSTRACT: Cultural beliefs and attitudes have been identified as significant contributing factors in the development of eating disorders. Rates of these disorders appear to vary among different racial/ethnic and national groups, and they also change across time as cultures evolve. Eating disorders are, in fact, more prevalent within various cultural groups than previously recognized, both within American ethnic minorities and those in other countries. This review examines evidence for the role of culture as an etiological factor for the development of eating disorders. Historical and cross-cultural experiences suggest that cultural change itself may be associated with increased vulnerability to eating disorders, especially when values about physical aesthetics are involved. Such change may occur across time within a given society, or on an individual level, as when an immigrant moves into a new culture. Further research into the cultural factors that promote the development of eating disorders is much needed. Understanding how cultural forces contribute to the development of disorders is needed so that preventive interventions can be created.Psychiatry Interpersonal & Biological Processes 02/2001; 64(2):93-110. · 2.58 Impact Factor
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ABSTRACT: Sixty therapists randomly assigned to 1 of 2 priming conditions were primed with African American stereotypes or neutral words using 80-ms flash words on a computer screen. This procedure may activate information processing outside of conscious awareness. After this task, participants were exposed to a brief vignette introducing Mr. X, a patient referred for treatment, and then were asked to rate Mr. X on various dimensions. Results indicate that participants primed with stereotype words rated Mr. X significantly less favorably on hostility-related attributes and significantly more favorably on hostility-unrelated attributes than did participants primed with neutral words. The findings suggest that therapists can be affected by African American stereotypes in ways that produce negative or positive first impressions depending on the nature of the attribute that is rated.Journal of Consulting and Clinical Psychology 07/1999; 67(3):387-93. · 4.85 Impact Factor
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ABSTRACT: Recently there has been concern over the need for mental health research within ethnic minority populations, particularly Hispanic populations. Although there has been research focusing upon the similarity of mental health problems among Hispanic and Anglo-American samples, the absence of information regarding the cross-ethnic measurement equivalence of the assessment tools used in these comparisons seriously limits the interpretability of these findings. The two reported studies were designed to (a) examine the cross-ethnic functional and scalar equivalence of several mental health measures by examining the interrelations of these mental health indicators and examining the regression equations using negative life events to predict mental health outcomes; and (b) compare several mental health indicators among Hispanic and Anglo-American 8- to 14-year-old children. Findings suggest considerable cross-ethnic functional and scalar equivalence for the measure of depression, conduct disorders, and negative life events. In addition, findings indicate that the Hispanic children scored higher in depression than did the Anglo-American children, but this difference could be a function of differences in SES. The reader is cautioned that the present samples included only English-speaking and primarily Mexican American children.American Journal of Community Psychology 01/1995; 22(6):767-83. · 1.74 Impact Factor
Culturally Competent Systems of Care
for Children’s Mental Health:
Advances and Challenges
Andre ´s J. Pumariega, M.D.
Kenneth Rogers, M.D.
Eugenio Rothe, M.D.
ABSTRACT: There has been a remarkable growth in cultural diversity in the United
States over the past 20 years. The population of minority groups has increased at a
much faster rate than the European-background population in America, and faster
even among children and youth. At the same time, minority youth face increasing
disparities in their mental health and in access to mental health services. These are
related to the multiple challenges they already face in socioeconomic status, but are
aggravated by the lack of culturally competent services that can address their specific
mental health needs within the context of their culture, family, and community. This
paper reviews the current knowledge about the mental health of culturally diverse
youth in the United States, and provides guidance on approaches to address the
disparities they face.
Recent demographic changes in the United States have underscored
the centrality of cultural competence in mental health service delivery
systems in child mental health. The past 20 years have witnessed a
remarkable growth in the population of many minority groups,
increasing at a much faster rate than the European-origin population.
In many areas of the United States, including most large cities and
Andre ´s J. Pumariega is affiliated with the Child and Adolescent Psychiatry, East Tennessee State
University, Johnson City, TN 37614.
Kenneth Rogers is affiliated with the Child and Adolescent Psychiatry Residency Program,
University of Maryland, Baltimore, MD.
Eugenio Rothe is affilated with the Child and Adolescent Psychiatry Outpatient Services,
University of Miami School of Medicine, Miami, FL.
Address correspondence to Andres J. Pumariega, M.D., Child and Adolescent Psychiatry, East
Tennessee State University, 204 McWherter Hall, Box 70567, Johnson City, TN 37614; e-mail:
Community Mental Health Journal, Vol. 41, No. 5, October 2005 (? 2005)
? 2005 Springer Science+Business Media, Inc.
many states, there are no longer numerical minorities, but a plurality
of various ethnic, racial, and cultural groups. By the year 2050 there
will be no numerical majority population in the United States, and for
children and youth. These changes are most rapid in areas not typically
associated with diverse populations, such as the South and Midwest
(U.S. Census, 2000).
These growing minority populations comprise a wide array of races,
ethnicities, and countries of origin. Most differ substantially in their
value systems and beliefs compared to European?backgrounds popu-
lations. Many minority children, (particularly the four underserved
and underrepresented ethnic/racial groups: African?Americans, Lati-
nos/Hispanics, Asian?Americans, and American Indians) suffer from
inequities in socioeconomic status, education, and access to culturally
and linguistically appropriate health and human services. These are
reflected in significantly lower mean household income and levels of
education, higher mortality rates (including infant mortality), higher
school drop-out rates, high teen pregnancy rates, unemployment, and
higher rates of physical and mental health disparities. (U.S. Office of
the Surgeon General, 2001).
IMPACT OF CULTURE ON DEVELOPMENT, HEALTH AND
A conceptual framework of the role of culture in health and human
behavior is necessary to understand the health needs of culturally di-
verse children and populations.
Cultural Influences on Development
Human psychological development is a key process through which
culture influences behavior and adaptation. Cultural values help define
childrearing practices and developmental norms (including behavior-
ally and emotionally) and expectations for such landmarks as toilet
training, when to leave a child unsupervised, readiness for expression
of sexuality and intimacy, and readiness to leave the parental home.
Expected role functioning in different contexts is culturally governed,
including gender, familial, and occupational roles. Patterns of inter-
personal communication are largely determined by culture. For
example, amongst different Latino groups there are differences in
affective expressiveness, with some being more reserved while others
540 Community Mental Health Journal
are more expressive. Thresholds for problem behaviors and adaptive
psychological strategies differ widely amongst cultures. For example,
hyperactivity in male children is not seen as abnormal by different
groups (including Latinos and African?Americans), while for others it
may deviant (such as Caucasians and Asian?Americans). Some cul-
tures value coping mechanisms such as sublimation of emotions, while
others value humor, abreaction, and the use of rituals or artistic forms
(Powell, Yamamoto, Romero, & Morales, 1983).
A child responds to such cultural expectations in their family and
community. However, for most diverse children, this involves being
conversant with at least two cultural systems. The optimal adaptation
for minority youth is bi-culturality or even multi-culturality (de Anda,
1984). This implies the development of knowledge, skills, and under-
standing in at least two cultures; while the youth retains his/her original
cultural identity, they become adept at interfacing with the mainstream
culture. It also implies flexibility to operate in different cultural contexts,
the development of a stable self image, selective adoption of the most
adaptive values and beliefs of different cultures, and openness to dif-
ferent cultural perspectives. Inability to develop these characteristics
can lead to margination into the culture of origin, over-acculturation to
the mainstream culture, identity diffusion, or negative identity forma-
tion (Erikson, 1968). Sue (1981) suggests that the identity formation
process in diverse youth can be assessed and interventions designed to
facilitate the development of a healthy bi-cultural adjustment. However,
behaviors offensive to the larger society are often exhibited during
identity development, causing potential helpers (such as teachers,
counselors, and even clinicians) to view a healthy but painful process as
pathologic. Inappropriate or overly punitive responses can also inhibit
healthy outcomes and contribute to identity diffusion.
Cultural Influences on Mental Health
Value orientation influences health beliefs and practices. For example,
nature, time, and activity orientations influence health maintenance or
preventive practices, perceived locus of control, and health risk
behaviors. The roles of the family as arbiter of health practices and
primary caregivers are influenced by relational value orientations. The
roles of healers are culturally determined; some cultures expect healers
to assume an authoritarian role, and others a more egalitarian role
(Callan & Littlewood, 1998). Attributional beliefs about physical and
mental illness are largely culturally determined, with illness viewed
Andre ´s J. Pumariega, M.D., et al.541
through Western biopsychosocial beliefs, or through religious, spiri-
tual, interpersonal, and/or supernatural beliefs. Culture defines the
sick role, with ‘‘sick’’ individuals expected to behave in a fragile man-
ner, continue functioning in spite of their illness, or have a special
spiritual role for the society. Finally, cultural values and beliefs influ-
ence patterns of help-seeking behavior, with people of different cultures
seeking assistance from neighborhood wise ladies or ‘‘co-madres‘‘, tra-
ditional healers, physicians, or mental health professionals. The ori-
entation of traditional healers and their healing approaches are
governed by attributional beliefs, and their practices differ greatly from
those of the professional establishment (ceremonies/rituals, incanta-
tions, prayers, herbal remedies, sweat lodges, spiritual counseling, etc.;
Rogler & Cortes, 1993).
Culture has a major influence on how we experience, understand, ex-
press, and address emotional, behavioral, and mental distress. Somati-
zation and anger, for example, are symptoms frequently associated with
depression and anxiety disorders in minority youth (Malgady, Rogler, &
Dharma, 1996). Different contexts for idiomatic expressions determine
how distress is expressed (e.g. ‘‘feeling blue’’ has clinical meaning for
Caucasians, socio/historical meaning for African?Americans, but is
problems (Bracero, 1998).
DISPARITIES IN MENTAL HEALTH SERVICES FOR MINORITY
CHILDREN AND YOUTH
Minority children and youth face a number of barriers to effective
mental health care. These include population barriers (socioeconomic
disparities, stigma, poor health education, lack of activism), provider
factors (deficits in cross-cultural knowledge, skills, patient-orientation,
and attitudinal sensitivity), and systemic factors (services location and
organization, training, culturally competent services, etc.). These bar-
riers result in different types of mental health disparities amongst
minority children and youth.
Misdiagnosis and Misalliance
There is significant evidence that psychiatric disorders are frequently
misdiagnosed amongst culturally diverse youth. For example, Kilgus,
542Community Mental Health Journal
Pumariega, and Cuffe (1995) found African-American youth were as-
signed significantly more diagnoses of solitary conduct disorder and
psychosis, fewer diagnoses of mood and anxiety disorders, substance
abuse disorders, and personality disorders, and more frequent invol-
untary commitments than Caucasian youth on an adolescent inpatient
service. However, both groups had the same level of aggressive and self-
injurious behaviors during treatment. Hong, Pumariega, and Licata
(2002) found diagnoses for Caucasian, African-Americans, and youth of
other ethnicities in a state public mental health system were dependent
on their relative minority/ majority status in their region.
Misdiagnosis largely originates from difficulties that clinicians from
majority and minority origins have in addressing cultural difference.
Effectiveness in addressing cultural factors is not only related to
knowledge about the family’s culture, but also the clinician’s ability to
form a patient- and family-centered alliance in which the clinician re-
spects the family’s knowledge and unique perspectives on the child,
avoids stereotyping, and empowers them to make critical treatment
decisions. Cooper et al. (2003) demonstrated that the failure to form
such alliances contributes to significant barriers in assessment and
subsequent use of health services by minority patients, while race-
concordant clinician-patient pairs tended to prevent such misalliance.
Psychopathology Amongst Minority Youth
Risk factors for psychopathology are influenced by cultural background
and immigration status. Risks for certain forms of psychopathology are
common in mainstream populations, such as substance abuse, eating
disorders, and suicidality, increase with exposure to Western cultural
values and practices (Pumariega, Swanson, Holzer, Linskey, & Quinte-
ro-Salinas, 1992; Swanson, Linskey, Quintero-Salinas, Pumariega, &
Holzer, 1992; De La Rosa, Vega, & Radisch, 2000; Miller & Pumariega,
2001). This increase in risk may result from loss of protective cultural
values and beliefs (such as attitudes and taboos on the use of substances,
suicide, and body image) and exposure to risk enhancing factors (such as
immigration and acculturation stressors, media exposure, peer pressure,
and less family support). Inter-generational conflict between more cul-
turally traditional parents and more acculturated youth has been found
to lead to increased substance abuse and conduct disturbance
(Szapocznik, Scopetta, & Tillman , 1978).
While some studies have shown lower rates of depression amongst
African-American youth than Caucasians (Angold et al., 2002), other
Andre ´s J. Pumariega, M.D., et al.543