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: Multicultural responsiveness and adaptation have been a recent area of emphasis in prevention and intervention science. The changing demographics of the United States demand the development of intervention strategies that are acceptable and effective for diverse cultural and ethnic groups. The Family Check-Up (FCU) was developed to be an intervention framework that is flexible and adaptive to diverse cultural groups (Dishion & Stormshak, 2007 ). We empirically evaluated the extent to which the intervention is effective for improving youth adjustment and parent-child interactions for diverse cultural groups. A sample of 1,193 families was drawn from 2 large-scale randomized prevention trials conducted in diverse urban middle schools. We formulated 3 groups on the basis of youth self-identification of ethnicity (European American, African American, Hispanic) and examined group differences in the hypothesized mediating effect of family conflict (FC) on later antisocial behavior (ASB). Path analysis revealed that youths in the intervention condition reported significantly less ASB over a 2-year period (Grades 6-8). Moreover, youth-reported reductions in FC at 12 months were an intervening effect. Ethnicity did not moderate this relationship. Consistent with one of the primary tenets of coercion theory, participation in the FCU acts on ASB through FC across diverse ethnic groups, lending support to the multicultural competence of the model. Limitations of this study are discussed, along with areas for future research.Journal of Clinical Child & Adolescent Psychology 04/2014; · 1.92 Impact Factor
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ABSTRACT: Schools are in a unique position to offer mental health support adapted to the needs and to the varying situations of children. One way to reach a wide number of children for mental healthcare interventions is through classroom-based programs. While several instances of creative arts therapies school projects are found in the literature, no critical review of classroom-based creative expression programs exists to date. Following a review of scientific publications, 19 articles referring to 8 different programs were identified and examined in order to explore what are the effects of classroom-based creative expression interventions on children's mental health. Overall, the results indicate that programs containing a major component of creative expression can be beneficial to children but this needs to be considered with moderation. On one hand, significant improvement was found in hope, coping and resiliency, prosocial behaviors, self-esteem, impairment, emotional and behavioral problems (especially aggressive behaviors), construction of meaning and PTSD scores. On the other hand, some studies also reported no significant change in prosocial behaviors, self-esteem, emotional and behavioral problems, coping and resiliency of adolescent boys and PTSD (for a lack of a targeted intervention). These mixed results raise important questions that need to be addressed in future research.The Arts in Psychotherapy 07/2014; · 0.58 Impact Factor
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ABSTRACT: Urban schools lag behind non-urban schools in attending to the behavioral health needs of their students. This is especially evident with regard to the level of use of evidence-based interventions with school children. Increased used of evidence-based interventions in urban schools would contribute to reducing mental health services disparities in low-income communities. School-wide positive behavioral interventions and supports (SWPBIS) is a service delivery framework that can be used to deliver universal preventive interventions and evidence-based behavioral health treatments, such as group cognitive behavioral therapy. In this article, we describe our ongoing research on creating internal capacity for program implementation. We also examine the cost-effectiveness and resulting school climate when two different levels of external support are provided to personnel as they implement a two-tier SWPBIS program.Methods/design: The study follows six K - 8 schools in the School District of Philadelphia randomly assigned to consultation support or consultation-plus-coaching support. Participants are: approximately 48 leadership team members, 180 school staff and 3,900 students in Tier 1, and 12 counselors, and 306 child participants in Tier 2. Children who meet inclusion criteria for Tier 2 will participate in group cognitive behavioral therapy for externalizing or anxiety disorders. The study has three phases, baseline/training, implementation, and sustainability. We will measure implementation outcomes, service outcomes, child outcomes, and cost. Findings from this study will provide evidence as to the appropriateness of school-wide prevention and treatment service delivery models for addressing services disparities in schools. The effectiveness and cost-effectiveness analyses of the two levels of training and consultation should help urban school districts and policymakers with the planning and deployment of cost-effective strategies for the implementation of evidence-based interventions for some of the most common behavioral health problems in school children.Trial registration: ClinicalTrials.gov identifier: NCT01941069.Implementation Science 01/2014; 9(1):12. · 2.37 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
540Community 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,
542 Community 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
studies have found higher rates of depression amongst minority
(including African-American, Latino, and American Indian) youth than
Caucasians (Roberts, Roberts, & Chen, 1997; Doi, Roberts, Takeuchi, &
Suzuki, 2001). There is also significant race/ethnicity by gender inter-
actions, with depression being higher in African-American versus
Caucasian males but comparable between African-American and
Caucasian female children (Kistner, David, & White, 2003). Though
suicide rates for minority youth had been traditionally lower, they have
had recent epidemic and now equal or surpass those for white youth.
American Indian youth now have the highest suicide rate of all ethnic
groups in the United States, and major increases have been docu-
mented for African-American and Latino males as well as Latino fe-
males. Contributing factors in addition to mental illness include
acculturation pressures, discrimination, gender role pressures, past
traumas and losses, and poverty (Borowski, Resnick, Ireland, & Blum,
1999; Olvera, 2001; Willis, Coombs, Cockerham, & Frison, 2002).
Studies have pointed to higher rates of anxiety symptoms and
diagnoses amongst minority children and youth (Glover, Pumariega,
Holzer, & Nguyen, 1999). Minority youth are at higher risk for child
abuse and its sequelae when compared to whites, especially given
socioeconomic disparities (Randall & Parilla, 2001). Coupled with
exposure to community and domestic violence as well as traumas in-
curred in the process of immigration, minority children and youth are
more vulnerable to post-traumatic and acute stress disorder symp-
tomatology (Cooley-Quille, Boyd, Frantz, & Walsh, 2001; Rothe et al.,
2002). These symptoms are complicated by the loss of family supports
and familiarity of surroundings resulting from immigration, accultur-
ation, and margination (Guarnaccia & Lopez, 1998).
Though recent studies suggest lower overall levels of drug abuse by
minority youth compared to Caucasians, there is still significant mor-
bidity from alcohol, cocaine, amphetamines, and hallucinogens. Al-
though minority youth may use fewer substances than white youth,
they are more likely to develop substance use problems as adults if they
use alcohol during adolescence (Pumariega, Kilgus, & Rodriguez,
Aggressive behavior has been frequently associated with minority
youth. However, while there is no evidence of higher rates of behavior
disorders independent of substance abuse, many other factors con-
tribute to violent behavior by minority youth including acculturation
pressures, domestic violence, poverty, and substance abuse (Grun-
baum, Basen-Engquist, & Pandey, 1998). Though often over-diagnosed,
544Community Mental Health Journal
there is no evidence that psychosis related to schizophrenia or bi-polar
disorders are more prevalent amongst minority populations than
amongst whites (Kilgus et al., 1995). However, manic psychosis is mis-
diagnosed as conduct disturbance in minority youth (Disalver, 2001).
Additionally, cultural context affects the phenomenology and expres-
sion of hallucinations and delusions in these disorders (Suhail &
The definition for culture-bound syndromes is outlined in the Cultural
Formulation of the Diagnostic and Statistical Manual of the American
Psychiatric Association (DSM-IV- TR, American Psychiatric Association,
2000). Many culture bound syndromes have combined acute anxiety,
dissociative, and even psychotic symptoms. These have associated
spiritual, supernatural, and interpersonal attributions consistent with
the individual’s culture. The prevalence of culture-bound syndromes in
children and youth is unknown and requires further research, though it
is likely that their prevalence is lower than in adults given their higher
level of acculturation (Canino, Canino, & Arroyo, 1998).
Access to Mental Health Services
Minority youth in the United States face considerable disparities in
their use of mental health care services. In addition to the previously
listed barriers posed by our health system, many minority families are
suspicious of the mental health system and are less likely to seek care
in such a system. African?American families have past experiences
with discrimination, oppression, and involuntary treatment in the
mental health system (Sussman, Robins, & Earls, 1987). Hispanic
families underutilize mental health services due to language and cul-
tural barriers (Ruiz & Langrod, 1997), while Asians?Americans expe-
rience shame around mental illness (Gaw, 1993).
All of these factors result in significant underutilization of commu-
nity mental health services by minority youth and their families. Zito,
Safer, Dosreis, and Riddle (1998) studied children 5 through 15 years
old, enrolled in the Maryland Medicaid system. They found that
Caucasian youth were two and a half times more likely than Afri-
can?Americans to receive any type of psychotropic medication, and
African?Americans received fewer prescriptions and had fewer physi-
cian visits. These findings coincide with those of Cuffe, Waller, Cuccaro,
Pumariega, and Garrison (1995) that African-American youth receive
significantly lower rates of treatment than whites and stay in treat-
ment half the time as white children. Latino children receive an
Andre ´s J. Pumariega, M.D., et al. 545
average of half as many counseling sessions (Pumariega, Glover, Hol-
zer, and Nguyen, 1998), and receive significantly fewer specialty
mental health services and at a later age (Hough et al., 2002), than
Caucasians and African?Americans. Minority youth are less likely to
receive multimodality treatment for ADHD (Bussing, Zima, & Belin,
1998). Additionally, there are fewer pediatricians, family physicians
and psychiatrists practicing in inner city and low-income areas where
minority populations live (Rowland, 1994).
Lack of access to services and ineffective services for minority youth
has resulted in increasing numbers of them entering the juvenile jus-
tice and child welfare systems (Pumariega, Johnson, Sheridan, &
Cuffe, 1995; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). In
fact, youth entering into juvenile justice have a significantly lower rate
of access to acute and outpatient mental health services compared to
youth already served by mental health, but higher rates of residential
placements (Pumariega et al., 1999).
CULTURAL COMPETENCE IN CHILDREN’S MENTAL HEALTH
Cultural competence became one of the core principles of the children’s
system of care movement. Cross, Bazron, Dennis, and Isaacs (1989)
defined cultural competence as a ‘‘set of congruent behaviors, attitudes,
and policies found in a system, agency, or a group of professionals that
enables them to work effectively in a context of cultural difference.’’
They identified a spectrum of cultural competence which has been
demonstrated by societies and their institutions over centuries, ranging
from cultural destructiveness (genocide, lynching, ethnic cleansing),
cultural incapacity (segregation, discrimination, immigration quotas,
services which break up families), cultural blindness (‘‘equal’’ treat-
ment for all, but not making distinctions in services offered on differ-
ences in values or beliefs), cultural pre-competency (realization of
differences but insufficient provision of services), to cultural compe-
tence. Few societies have achieved the last stage, cultural proficiency
(provision of innovative culturally specific services and research.)
Clinical Application of Cultural Competence Principles
Cross et al. (1989) defined the qualities of culturally competent prac-
titioners and agencies. For the individual practitioner, they included
546 Community Mental Health Journal
qualities such as being aware and accepting of cultural differences,
awareness of their own culture and the biases it may create, under-
standing the dynamics of working across cultures, acquisition of cul-
tural knowledge, and acquiring and adapting practice skills to fit the
cultural context of the client.
or disorders need to be addressed in clinical evaluations. Differences in
interpretation of emotional experiences, labeling and interpretation of
symptoms, and degree of self-disclosure affect the cross-cultural and
cross-ethnic validity of clinical assessment and most diagnostic instru-
ments (Abreu, 1999). Results from any diagnostic instruments require
interpretation within the youngster’s socio-cultural context and support
by careful clinical observation (Knight, Virdin, Ocampo, & Roosa, 1994).
Factors such as stigma, social acceptability, and parental disapproval
should be considered in evaluating critical symptoms.
Language and communication are critical in obtaining accurate
clinical information and establishing a therapeutic alliance, especially
with family members. However, translation and interpretation are
typically considered a menial or informal task rather than one central
to the clinical process. This is reflected in the use of telephonic trans-
lation services, untrained translators, and family members; particu-
larly the use of siblings or the child without regard to the impact on
family relations. This latter practice should be prohibited except in dire
emergencies due to the adverse impact it has on children and on family
relations. Interpreters should have proper training in both the skill of
translation and in the content area of interpretation. They should
understand the family’s culture and address verbal, non-verbal, and
implicit communications (Four Racial/ Ethnic Panels, 1999).
The cultural and family context of symptomatology (for example,
normative crises such as grief or mourning) must be considered in the
assessment of a minority child. One must also assess whether cross-
cultural dynamics may play a role in the symptomatology (such as
inter-generational conflicts around acculturation, discrimination, or
marginalization from the majority culture or the youth’s own culture).
Additionally, whether a cultural healer or herbal remedy was at-
tempted or considered (or failed) should be ascertained. The utilization
of a cultural consultant, with the family’s consent, can also be useful in
dealing with issues related to traditional beliefs and values, as well as
their potential distortion (for example, whether spiritual preoccupa-
tions are consistent with the family’s cultural or religious practices or
are a psychotic distortion).
Andre ´s J. Pumariega, M.D., et al.547
Treatment of minority children must be contextual, addressing
psychosocial and cultural needs. The clinician must evaluate and
mobilize familial, neighborhood, and community resources, address
environmental factors that contribute to behavioral problems, and en-
hance strengths the child and family bring to address the problem. The
clinician should support parents in developing practical behavioral
management skills consonant with their cultural values and beliefs.
They must respect culturally established means of communication and
family role functioning, but at the same time foster family flexibility in
dealing with their bi-cultural offspring (Koss-Chioino & Vargas, 1999).
Psychosocial interventions should be consonant with the values and
beliefs of culturally diverse youth and their families. Culturally diverse
children and families are more accepting and responsive to psycho-
therapeutic approaches with a practical problem-based and interper-
sonal focus. Cognitive-behavioral and interpersonal therapies, which
are oriented towards these principles, are being increasingly used with
diverse youth, with studies suggesting good response (Williams,
Chambless, & Steketee, 1998; Mufson, Weissman, Moreau, & Garfin-
kel, 1999; Rosello & Bernal, 1999). Psychoanalytically oriented inter-
ventions have tended to include inherent cultural biases, (such as
encouraging separation-individuation and challenge of traditional
parental authority and roles) which are counterproductive in working
with culturally traditional families (Cabaniss, Oquendo, & Singer,
1994). However, when cultural values and beliefs are addressed, di-
verse youth can benefit from psychoanalytic therapy (Aslami, 1997).
Some therapists have developed specific interventions for particular
ethnic and racial groups (Constantino, Malgady, & Rogler, 1994; De
Rios, 1997). Group and family psychotherapy, particularly approaches
that integrate cultural and ethnic identity themes, psychoeducation,
and culturally consonant approaches, have also been reported as ac-
cepted and effective (Szapocznik & Kurtines, 1989; Salvendy, 1999).
Mainstream interventions also need to be tailored when used to treat
minority children. For example, minority children with ADHD and
their families cooperated with and responded significantly better to
combined pharmacological and behavioral treatment, while Caucasian
children responded to pharmacotherapy alone, even controlling for
socioeconomic factors (Arnold et al., 2003).
The integration of consultation and intervention by traditional
healers and ceremonies from diverse cultures is an important compo-
nent of culturally competent care. Such practices should only be pur-
sued if they are acceptable and desired by the child and family
548 Community Mental Health Journal
(Four Racial Ethnic Panels, 1999). Clinicians from the culture of origin
are preferable, though clinicians knowledgeable about the family’s
culture and sensitive to its meaning and importance can also be
effective. Referral to culturally competent clinicians or culturally spe-
cific programs has been associated with improved follow-up and
treatment retention (O’Sullivan & Lasso, 1992). A value-neutral ap-
proach, where the clinician models openness to the diverse cultural
influences on the child, is effective in achieving these goals (Ponterotto,
Casas, Suzuki, & Alexander, 2001). The therapist can also use judicious
self-disclosure with the child when he/she experienced any of these
conflicts. Confidentiality in psychotherapy must be addressed so the
clinician is not perceived as ‘‘driving a wedge‘‘ between the patient and
family, nor used by the patient to resist dealing with family issues
Home or community-based alternatives to hospitalization usually
result in better outcomes for diverse children and youth, while invol-
untary hospitalization tends to re-create past traumas of oppression
(Herrera, 1996; Garrison, Roy, & Azar, 1999). If at all possible, out of
home placement should be accomplished with the cooperation of the
family and youth. An interagency approach within a system of care
orientation is consistent with cultural competence since it uses com-
munity resources and empowers the child and family to a maximum
extent (Koss-Chioino & Vargas, 1999).
The new science of ethnopsychopharmacology points to genetic and
nutritional factors that contribute to differential pharmacological re-
sponse across ethnic and racial groups. Genetic polymorphisms have
been described for many drug-metabolizing enzymes in Causasian,
Asian, and African-origin populations (Smith & Mendoza, 1996).
Additionally, nutritional factors such as citrus and corn dietary con-
tent, which vary in different ethnic groups, inhibit the action of some of
these enzymes. A higher prevalence of extrapyramidal symptoms from
antipsychotics in African and Asian-origin populations may be related
to metabolic differences (Zhang-Wong, Beiser, Zipursky, & Bean, 1998).
Differences in hepatic aldehyde metabolism in American Indians and
Asian Americans determine degree of intoxication from alcohol and
related substances. Knowledge about substances of abuse and herbal
remedies in diverse populations, and their interactions with medica-
tions, is also important (Smith & Mendoza, 1996).
There are also interpersonal aspects of pharmacotherapy with
minority children and youth that require careful attention. These in-
clude proper informed consent and family collaboration, particularly
Andre ´s J. Pumariega, M.D., et al.549
with traditional cultural family decision-makers (typically outside of
the nuclear family); demystification of medications (not only education
on their mechanisms of action, but also addressing suspicions about use
for mind control and suppression of emotions); and empowerment of
youth and families to make medication choices address perceived (and
real) power differentials with clinicians.
Application of Cultural Competence Principles to Systems of Care
As outlined by Cross et al. (1989), there are four main qualities to be
demonstrated by culturally competent agencies or institutions: valuing
and adapting to cultural diversity; on-going organizational self-
assessment; understanding and managing the dynamics of cultural
difference; the institutionalization of cultural knowledge and skills
through training, experience, and literature; and instituting service
adaptations to better serve culturally diverse clients and their fami-
Mental health services for minority and culturally diverse popula-
tions should be located in community settings where diverse popula-
tions feel comfortable accessing services. Services that are associated
with institutions that are viewed favorably in the community, such as
religious institutions, primary care settings, and non-medical settings
such as schools, are often less threatening and more easily accessed
than a traditional mental health clinic. Tertiary medical centers are
venues of last resort for diverse populations, associated with death or
involuntary long-term institutionalization. Reduced bureaucratic bar-
riers and a personalized but respectful approach are important to
facilitate access to services (Four Racial and Ethnic Panels, 1999).
Culturally competent practice can only occur within a system of care
that has internalized and integrated cultural competence principles into
every aspect of its organization and functioning. This requires an oper-
ationalization of how cultural competence is applied within these sys-
tems. Further impetus has been provided by the advent of managed care.
Minority populations, particularly children, are widely covered under
Medicaid, which is increasingly under state-sponsored managed care
programs. Public managed behavioral health, combined with privatiza-
tion, has adopted approaches that fail to address the multiple stressors
faced by diverse children and families. It has also relocated many mental
health services away from minority community settings, and selected
against minority practitioners in provider panels due to fewer ‘‘formal’’
credentials and serving ‘‘higher-risk’’ inner-city or rural clients.
550 Community Mental Health Journal
The response to these challenges has been to further operationalize
the definition of culturally competent mental health services both at
the provider and the systems level. This has led to the development of
standards for culturally competent mental health services for mental
health practitioners, provider organizations, health plans, and orga-
nized systems of care. Examples of such standards include the Center
for Mental Health Services cultural competence standards (Four Ra-
cial/Ethnic Panels, 1999) and the cultural and linguistic standards of
the U.S. Office of Minority Health (2000). These outline specific system
standards (including governance, benefit design, quality assurance/
improvement, information systems, and staff training and support) and
clinical standards (access portals, triage and assessment, care plan-
ning, case management, treatment services, case management, and
linguistic support). They outline cultural competence planning pro-
cesses for systems of care based on needs assessments of diverse pop-
ulations being served involving the leadership and front line providers.
Work in the area of cultural competence in children’s mental health
continues to evolve and develop as the fields of business, education,
health care, and human services become aware of its importance to our
multicultural society. The Surgeon General’s supplement on mental
health, culture, race, and ethnicity (U.S. Office of the Surgeon General,
2001) has further outlined significant issues in ethnic/racial mental
health disparities and the need for expanding research in this impor-
tant area. This report has complemented the Federal initiative on
health disparities, which involves the identification inequalities not
only in mental health status, but also in physical health. Research in
epidemiology and services research examining mental health dispari-
ties for minority and underserved youth is also pointing the way to-
wards the system of care reforms needed to improve the cultural
competence of child mental health services.
However, as Cross et al. (1989) clearly asserted, the advancement of
knowledge and skills needs to be matched with similar progress in
attitudes in order for true progress towards a culturally pluralistic and
proficient system of care. It will be up to us as front-line practitioners in
community systems of care to use the new knowledge about the influ-
ence of culture, race, and ethnicity in mental health, but also face the
old ugly specters of prejudice and discrimination that still affect all of
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