Supporting children, youth and families in the systems that serve them: Culturally responsive practices and policies to meet their needs
The color of America is evolving. Between 2000 and 2010 there was a 43 precent increase in both Asian-Americans and Latinos and a 32 percent increase in bi/multiracial individuals (U.S. Census Bureau, 2011). In 2010, 43 percent of the U.S. population came from the four major ethnic/racial groups. By 2050, Latinos are projected to make up one third of the U.S. population and one-fourth of children in the U.S. will be Latino (U.S. Census Bureau, 2011). Moreover, the number of children five to 17 years old who spoke a language other than English at home increased 21 percent between 1980 and 2009. Among Latino and Asian-American children, 16 percent speak a non-English language at home compared to 1 percent of white, black, or bi/multiracial children (U.S. Department of Education, 2011). These changing demographics have resulted in a major cultural, social, and economic shift in health and mental health needs and require culturally appropriate resources to meet the behavioral health challenges of these growing populations, especially children.
Disparities in access to quality mental health services/supports exist for youth from particular ethnic/racial groups. Latino youth are one third, and African-American and Asian-American/Pacific Islander youth are one half, as likely to receive needed mental health services compared to white children. Youth from racial/ethnic minority groups also are more likely to receive treatment that is not appropriate, fragmented or inadequate (Holm-Hansen, 2006).The challenges in meeting the behavioral health needs of these children are compounded by the disproportionate number of children and families from racial/ethnic groups living in poverty.
In 2008, 14 million American children lived in families with incomes below the federal poverty level, a 21 percent increase from 2000, and 29 million (41 percent) lived in federally defined low-income families (Wight, Chau, & Aratani, 2010). Eleven percent of white children live in poor families compared to 35 percent of black, 15 percent of Asian, and 31 precent of Latino children (NCCP, 2010). Significantly, poverty and mental health are strongly associated. Twenty-one percent of low-income children and youth aged six to 17 have mental health problems and 57 percent of children and youth with mental health problems come from households at or below the federal poverty level (Howell, 2004). A child whose family is living in poverty is three times more likely to have a mental health problem (Lipman & Boyle, 2008).
In addition to poverty, there are many other reasons for disparities in access to quality mental health care for children of color including racism, historical trauma, lack of health insurance or limited coverage (Miranda, McGuire, Williams, & Wang, 2008), differential response to treatment approaches and differential interpretation of behavior based on race/ethnicity (Holm-Hansen, 2006; Miranda et al., 2008). Children of color who are lesbian, gay, bisexual, or transgender (LGBT) may also encounter further stigma and institutionalized bias (Poirier, Martinez, Francis, Denney, Roepke, & Cayce, in press).
Recommended practices and policies for reducing mental health disparities
Given the changing U.S. demographics and the unmet mental health needs of youth from racial/ethnic groups, it is important to embrace system and organizational practices/policies that address and ultimately reduce these disparities. Such practices/policies include (but are not limited to):
Conducting culturally appropriate public health campaigns to increase awareness and identification of mental health issues among youth and families from racial/ethnic groups.
Providing culturally specific high-quality mental health services within other youth serving systems such as primary care, child welfare, juvenile justice and education.
Involving youth and their families in “driving” treatment planning, approaches and goal setting.
Recruiting, training, and retaining diverse staff that speak the language and reflect and understand the worldviews of youth/families from diverse racial/ethnic groups and LGBT identities.
Utilizing alternative, non-Western approaches to mental health care that respects and contributes to the youth/family’s understanding of the mental health issue (Holm-Hansen, 2006; Miranda et al., 2008; Poirier et al., in press).
Value-based, inclusive policy development and implementation processes
Policy development processes are as important as the policies themselves. Values-based, inclusive policy development processes can help address disparities in access to, and provision of, quality care and bring together affected stakeholders, ensuring their voices are heard, acknowledged and represented. Most importantly, this can enhance mental health outcomes at the individual and systems level by reducing disparities.
Interpretation of written words is not constant across different cultural groups. How a policy is framed may also reflect certain implicit (or even explicit) cultural biases and different world views. Hence, how policies are worded may not appropriately account for the cultural contexts of those children, youth and families affected. Such policies must be developed and administered in ways that are inclusive and follow three core values. These core valuescan further facilitate reductions in disparities and increases in positive outcomes. These include being (1) family-driven, (2) youth-guided and (3) culturally and linguistically competent.
Family-driven approaches require that families are involved in developing the policies/procedures that govern the care their children receive (National Federation of Families for Children’s Mental Health, 2010). This means that families are “at the table” and meaningfully contributing to discussions and decisions about the policies/procedures that will govern supports, services, and providers. It also means a shift in the way mental health agencies carry out their work: moving from being provider- to family-driven.
Similarly, youth-guided approaches necessitate a more meaningful role for youth in policy development, administration and practice. Youth involvement should be developmentally appropriate and they should be equal partners in systems change (Reid, 2011). Youth should also receive adequate, culturally and linguistically competent supports to prepare them to appropriately contribute to policy development and administration (Reid, 2011). For example, it is important to assess governing body members’ attitudes and beliefs about sharing decision making with youth, create safe spaces for this to occur, and provide training and mentoring so youth can fulfill expected roles (Reid, 2011).
Cultural and linguistic competence (CLC) is the third core principle required. CLC provides a conceptual framework for systems, agencies and practitioners to develop their capacity to effectively respond to the preferences, needs and identities of youth from diverse cultures (Poirier et al., in press). Various tools with recommended steps, such as development of a cultural and linguistic competence plan, are available to facilitate infusion of more culturally and linguistically competent policy approaches (e.g., Cultural and Linguistic Competence Implementation Guide).
Governance structures and managing teams should include children, youth and families from diverse racial/ethnic and linguistic backgrounds (Martinez et al., 2010) and these individuals should represent the local community, including LGBT populations (Poirier et al., in press). They can serve valuable roles as “cultural brokers,” facilitating communication and policy development. Cultural brokers are liaisons representing the values, beliefs and practices of a particular cultural group/community who are able to navigate mental health systems and can serve as cultural guides, mediate when there is distrust, and serve as change agents by fostering an inclusive environment (National Center for Cultural Competence, 2004). Purposeful and authentic engagement of cultural brokers can benefit policy development in systems and organizations, as well as children, youth and families, themselves.
A case example: Butte County, California
One example of a culturally informed and developmentally appropriate mental health intervention is “Culture-based Wraparound” developed and practiced by Connecting Circles of Care (CCOC) in Butte County, California. CCOC is a system of care funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and serves Latino, African American, Native American and Hmong children, youth and families. CCOC is implementing Wraparound, an “evidence-based process” that is values- and team-based for developing and implementing individualized care plans for children and families with complex needs that includes active participation by families, youth, natural support systems and an individualized community team (Stroul, 2002; Walker, Bruns, & Penn, 2008). CCOC integrates wraparound into the youth and families’ culture. This was a jointly developed practice that incorporated the cultural community’s needs and was endorsed by the county. It is now infused in their policies and is part of their service array.
Many cultures already utilize an inclusive family and natural support network and the CCOC process builds upon that culturally compatible practice. Families choose culture-specific services and supports such as Native American drumming or healing ceremonies led by Hmong shamans. Staff are fully bilingual, culturally matched, and view the world through the lens of the family’s culture. The nuances of cultural interpretations are not lost. Speaking in the native language precludes the shifting of power from the parents and elders to the provider or English-speaking children. It also allows the family and youth to express themselves emotionally in their native language instead of a foreign language that may not be able to communicate the true emotion or trauma involved. Specific family values, beliefs, and traditions are honored and valued but not seen separately as “culture” because they are viewed as integral to the family and their daily experience (Palmer et al., 2010). These culture-based wraparound interventions respect culture, enhance trust, facilitate successful outcomes, and prioritize the family, their culture, world view, and preferred mode of relating. It is truly a best practice example of culturally responsive and respectful policies and an intervention for diverse children, youth and families.
Kenneth J. Martínez, PsyD. Dr. Martínez is a clinical psychologist and principal researcher and mental health content specialist with the Technical Assistance Partnership for Child and Family Mental Health (TA Partnership), Human and Social Development, at the American Institutes for Research (AIR), Washington, D.C. He is lead for the TA Partnership’s Cultural Competence Action Team, which has published several cultural and linguistic competence related products. Martínez was the State Children’s Behavioral Health Director in New Mexico. He is also clinical assistant professor of psychiatry at the University of New Mexico Health Sciences Center and guest lecturer in the Department of Child and Family Studies at the University of South Florida. Martínez has served on the Rosalynn Carter Mental Health Symposium Planning Committee at the Carter Center and is currently vice president of the National Latino Behavioral Health Association, on the National Network to Eliminate Disparities in Behavioral Health Steward Group, and the National Advisory Committee for the Research and Training Center for Pathways to Positive Futures at Portland State University.
Jeffrey M. Poirier, PhD candidate, MA, PMP received his bachelor’s degree from the University of Pennsylvania and his master’s degree in education policy from The George Washington University, where he is currently completing a PhD in public policy. He is a senior researcher at AIR, where since 2000 he has researched and written about equity-related education and social issues, evaluated policy/program implementation, and provided technical assistance (TA) and consultation. Mr. Poirier is part of the TA Partnership, for which he leads the LGBT, Questioning, Intersex, and Two-Spirit (LGBTQI2-S) Learning Community. He has served as coordinator of SAMHSA’s National Workgroup to Address the Needs of LGBTQI2-S Children and Youth and Their Families since its inception in 2008. He is co-editor of a forthcoming Brookes Publishing volume, "Improving Emotional and Behavioral Outcomes for LGBT Youth: A Guide for Professionals."
Gina R. Hijjawi, PhD is deputy director for the Human and Social Development Program at the American Institutes for Research. Dr. Hijjawi specializes in the prevention of substance abuse and the translation of prevention science to inform a range of audiences including parents, practitioners and policy makers. Prior to joining AIR, Hijjawi worked as a policy analyst in the White House Office of National Drug Control Policy (ONDCP) in the Office of Demand Reduction. She also served as deputy director of research at the Partnership for a Drug-Free America. She was the AAAS/SRCD Executive Branch Fellow at the National Institute on Drug Abuse. Hijjawi is on the editorial board for The Prevention Researcher.
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