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Access to Care for Minority=
=
Youth:
The Role of Culturally Competent Services
Andres J. Pumariega, M.D.
Professor and Director, Child & Adolescent Psychiatry
James H. Quillen College of Medicine
East Tennessee State University
![](3D"master18_background.gif")
![](3D"master18_image002.gif")
Need and Rationale
lIncreasing culturally diverse population in U.S. &=
#13;
–Latinos,
African-American, Asian-American, American Indian
–No major=
ity
population by year 2050
–No major=
ity in
under 18 year olds by 2030
–Changes
already in NE, SW, and many large cities&=
nbsp;
Need and Rationale
lProblems with access to services
–Many stu=
dies
show higher prevalence of many disorders
(depression, anxiety, PTSD, etc.)
–Studies =
show
roughly equal MH need, but differences exist across populations and diagnoses
–Problems=
with
access to health and MH services
–Low numb=
ers of
MD’s from ethnic minority backgrounds
Need a=
nd
Rationale
lDiverse
populations with special needs for health and mental health
services
–Children
and adolescents (younger cohorts than Euro-Americans)
–Elderly/ geriatrics (future crisis)
–New
immigrants (cultural adaptation and stresses; many are childr=
en
and youth)
Surgeon General’s Report 2001
lRacial and =
ethnic
minorities less likely to receive quality care than g=
eneral
population
lOnly 1 in 3
Americans who need mental health services =
receive car=
e
lRacial and =
ethnic
minorities – higher burden of disability from
undertreatment or inadequate treatment
l4 most reco=
gnized
racial and ethnic groups in U.S.
–African Americans
–American Indian and Alaska Natives
–Asian Americans and Pacific Islanders
–Hispanic Americans
Mental Health: Culture, Race and Ethnicity
![](3D"slide0005_image005.gif")
U.S.
Dept.of Health and Human Services Office of the Surgeon General, SAMHSA Au=
gust
2001
Factors in Mental Health,
Mental Illness and Service Use
Mental Illness and Service Use
lRacism
=
lDiscriminat=
ion
lEconomic impoverishment
=
lMistrust=
3;
lFear
lCultural and
social influences
lBiological, psychological and environmental factors
U.S. Dept. of Health and Human
Services Office of the Surgeon General, SAMHSA August 2001
![](3D"slide0006_image007.gif")
Influence of Culture on
Mental Illness and Mental Health
Mental Illness and Mental Health
lHow patients
communicate
lHow patients
manifest symptoms
lHow patients
cope
lRange of fa=
mily
and community support
lWillingness=
to
seek treatment
U.S. De=
pt.
of Health and Human Services Office of the Surgeon General, SAMHSA August =
2001
![](3D"slide0007_image009.gif")
Mental
Health Disparities Faced by Minority/
Diverse Youth
Disproportionate
Psychosocial Risks Faced by
Minority Youth
lSchool
drop-out
–Highe=
st in
Latinos (only 40 % graduate from HS)
lTeen
pregnancy
–High =
in
Latinas and African-Americans
lViolence
and Criminal Activity
–High =
in
inner citites and reservations
lSuicidality
–Afric=
an-American
males, Latinas, and American Indian youth
lSubstance
Abuse
–Latinos and American Indians
particularly
lInstitutionalization
–Rising
numbers in child welfare and juvenile justice
Misdia=
gnosis
lFabrega, Ulrich, & Mezzich (1994): Over-diagno=
sis of
conduct disorder in
African-American youth.
lKilgus, Pumariega, & Cuffe (1995): Under-diagn=
osis
of depressive/ anxie=
ty and
personality disorders and over-diagnosis of psychosis and SA in African-American youth.
lHong, Pumariega, & Licata (1999): Over-diagnos=
is of
disruptive disorders and
psychosis; diagnosis correlates to minority status of youth in their region of the state.
lYeh, et al. (2002): Study of 3,962 youth in San Diego Co. MH
system Af-Am more =
dx
with V code, less dx with mood disorder; APIA’a =
more dx wit=
h V
code and less dx with ADHD; Latinos more dx with adjustment
disorders, anxiety disorders, and psychotic disorders and less dx wit=
h ADHD
than Non-Hispanic Whites. No significant racial/ ethnic
differences for CD, impulse control d/o, or SUD.
lMalgady & Constantino (1998) & others: Lan=
guage
in evaluation leads to
differences in diagnosis with Hispanics, even bilingual patients. <=
/span>
Lack of
Access to MH Services
–Bui &
Takeuchi (1992): Study of LA County Medicaid; Latino children had low use of outpatient MH services (36% of case=
s, 42%
of population).
–Cuffe,
Pumariega, & Garrison (1995): Lower treatment for African-American youth in community study of depression.&#=
13;
–Lahey et=
al.
(1996): Data from MECA study; diagnosed Puerto Rican youth used MH services less (20 %) than youth at o=
ther
sites (37-44%).
–Cunningh=
am
& Freiman (1996): Data from National Medical Expenditure Survey, Af-Am children less likely have MH outpati=
ent
visits than whites
–Shaffer =
et al.
(1996): Af-Am youth more likely to have unmet MH needs.
–Costello=
et al
(1997): Great Smoky Mt study; Af-Am and American Indian children under-utilized community MH services (mor=
e JJ
& inpatient).
–Zahner &=
amp;
Daskalakis (1997): Af-Am children less likely to receive MH =
treatment by specialists, by medical personnel, an=
d in
schools.
=
–Pumarieg=
a et
al. (1998): Texas Latino youth used signif. fewer counseling visits than
whites and Af-Am. Recent immigrants used fewest services.
–Chabra e=
t al.
(1999): Af-Am youth lower inpatient use, insurance factor.
–Novins e=
t al
(1999; 2000): Studies with Plain Indians; Am Indian children seen school services and juvenile detention; few t=
hrough
MH services.
–Juszczak,
Melinkovich, Kaplan (2003): Latino youth used fewer mean visits in school health centers than African-Ameri=
cans,
whites used least.
–
l
Lack
of Access to Community-Based MH
Services
lYeh et al.
(2002): 3,962 youth in San Diego Co. examined referral pa=
tterns
and services in outpatient MH
–Referral patterns: African-Am less likely referred from
schools, more likely referred by CW; APIA‘s more likely referred by=
CW,
Latinos more likely referred by family and less likely referred by =
MH
agency. No signif. diff. in crisis and medical facility referrals.
–Service type: Af-Am less likely than NHW’s to
receive Spec Ed Linked MH Assessment (SELMHAs) or day tx but more
likely to receive outpatient institutional services (in conjuction with CW
placements); APIA’s less likely to receive SELMHAs; Latinos more
likely to receive outpatient clinic services but less likely to receive SELMH=
As
or day treatement. No signif. diff. for crisis, case management, or
intensive CM.
–Latino utilization of outpatient services in San Diego Coun=
ty
aided by ethnic-specific Latino outpatient services- supports =
use of
such services. However, under-represented in other services (school MH
services for SED, day tx.,
school referrals/ SELMHAs).
<= /div>
<= /div>
Acce=
ss to
Evidence-Based Treatments
lZito et al. (1997): African-American children and =
youth receive less pharmacotherapy for ADHD than whites.=
lLatinos less likely to receive diagnosis of depres=
sion
or SSRI’s (Scla=
r et
al., 1999) or treatment using
evidence-based guidelines (=
Young
et al., 2001)
lAfrican-American less likely to receive guidelines=
-based
treatment (Wang et al., 2000; =
Young
et al., 2001), or SSRI&=
#8217;s
or any antidepressant when depression diagnosed (Malfi, et al., 2000), but receive higher dose of =
antipsychotics than whites (Walkup, et al., 2000) =
in
spite of lower metabolis=
m and
higher risk for EPS.
l<=
span
style=3D'mso-special-format:lastCR;display:none'>
Attitu=
des
To/ From MH System
lSussman et =
al.
(1987): 2.5 more African-Americans feared MH system than whites.
lBussing et =
al.
(1998): Af-Am parents less likely to describe child’s =
problems us=
ing
medical labels and more likely to expect short term course of
treatment than whites.
lPottick
& Davis (2001): 102 moth=
ers of
inner-city youths with MH problems and their 38 clinicians (aged
25-53). Greater causal responsibility was attributed to mothers =
by
professionals than by mothers, while agreed on children's responsibility. Mothers=
and
clinicians disagreed about their respective solution responsibilit=
ies, though agre=
eing
that children should help wi=
th
solutions. Mothers considered more community resources for solutions than
clinicians.
lYeh, et al. (2003): Latinos and other minority you=
th
showed higher level=
s of
unmet MH needs than whites, but parents of minority youth endorsed fewer barriers to care. Possibly related =
to
culture influencing percep=
tions
of barriers.
Div=
ersion
to Child Welfare System
lHalfon et al.
(1992): CW system major gatekeeper for MH services for Af-Am youth; A=
f-Am
children served in RTC’s (Firestone, 1990) and referred to pu=
blic
MH services primarily by child welfare (Bui & Takeuchi, 1992;
McCabe et al., 1999)
lPumariega, Joh=
nson,
Sheridan, & Cuffe (1994): High percentage of African-Americ=
an in
residential homes for children in Child Welfare, high prevalenc=
e of
depressive and substance abuse symptoms.
lGarland et =
al.
(1998): Representative sample in CW system, with 42% of children
meeting criteria for DSM diagnosis; 45% of children in CW African-=
Am
(DHHS, 1999)
lCross et al.
(2000): Up to 25 to 30 % of Am Indian children removed from their
families in past with major MH consequences to adults (Nelson et =
al.,
1996; Roll, 1998); led to Indian Child Welfare Act (1978) and
subsequent reductions.
lSheppard &a=
mp;
Benjamin-Coleman (2001): Placements for 2,803 Black and White y=
outh
served in the MH system. Controlling for SES and presenting pro=
blems,
Black youth more likely plac=
ed in
correctional facilities and foster care, White youth more li=
kely
hospitalized.
l
Dive=
rsion
to Juvenile Justice System
–Duclos (=
1988):
American Indian youth detainees; 49% with > 1 e MH or SA disorder; 1=
2.7%
had 2+ disorders; 8.7% had 3+. Most common dx: SUD (38%), CD
(16.7%), and MDD (10%). Females higher rates of dx.
–VanderSt=
oep,
Evens, & Taub (1997): High risk of referral of Latino youth to juvenile authorities for behavioral difficultie=
s.&=
#13;
–Atkins et al. (1999) & Pumariega et al. (1999): High
minority rep. (75%), high prevalence of disorders, and significant
under-utilization of MH services and residential over-utilization in sa=
mple
of incarcerated youth.
=
–Shelton (2001; Maryland JJ System): Used DISC plus <=
span
style=3D'mso-fareast-font-family:"MS Mincho";font-size:71%'><60 cut-off on =
the C-GAS; 53% had diagnosable mental disord=
ers on
DISC but above C-GAS cut-off; 46% met both criteria; 26% of youth
need immediate MH services; only=
14%
need restrictive environment by severity and offenses.
–Rogers e=
t al.
(2001, 2002): Under-referral of minority youth in JJ facilities.
–Wasserma=
n et
al. (2002): Voice DISC with 292 detained youth; rates of disorder compa=
rable
to prior studies. High rates of disruptive, SUD, anxiety and mo=
od
disorders, over 3% report past-month suicide attempt.
–Teplin e=
t al.
(1992): Largest study; findings consistent with above, even =
with Cook County Detention model for reducing mino=
rity
detention.
l
l
Approaches
to Improve Access to MH Services
for Minority Youth
lCultur=
al
Competence Model (Cross, Bazron, Dennis,
& Isaacs, 1989)
–For the individual: The state of being capable of functioning effectively in the context of cultural=
differences.
–For the organization: A set of congruent practice skills, attitudes, policies, and structures, which come to=
gether
in a system, agency, or among
professionals; and enabl=
e them
to work effectively in the context of cultural difference
Approaches
to Improve Access to MH Services
for Minority Youth
lPractitioner CC
=
;
lAwareness/ acceptan=
ce of
difference
lAwareness of own cultural
values
lUnderstanding dynamics
of difference
lDevelopment of cult=
ural
knowledge
lAbility to adapt
practice to cultural context of patient
l
lOrganizational CC
lValuing diversity
lCultural self-assessment
lManaging for the dynamics of
difference
lInstitutionalization of cultural
knowledge
lAdaptation to diversity (policies,
values, structure, and services)
Approaches
to Improve Access to MH Services
for Minority Youth
lCommunity System of Care Model/ Principles =
=
(Stroul & Friedman, 1986)
–Acces=
s to
comprehensive array of services
–Indiv=
idualized
services, needs and strengths
–Servi=
ces in
least restrictive environment
–Famil=
ies
should be full participants
–Servi=
ces
are integrated with agency linkages
–Case
management/ coordination
–Early
identification and prevention
–Smooth
transitions to adult services
–Servi=
ces
sensitive to cultural difference/ special needs
–
Approaches
to Improve Access to MH Services
for Minority Youth
lEvidence-Base for Mainstream Interventions
–Evidence=
-Base
for Usual Interventions MTA Study of ADHD:
Response to treatment for Latino and African-American children equal to whites; significantly b=
etter for combination CBT + meds than meds alone (whites=
responded equally to meds and combination in previ=
ous reports from MTA).
–Pina, et=
al.
(JAACAP, 2003): Equal response by Latino youth to exposure-based CBT for phobic and anxiety=
disorders.
–Henggele=
r, et
al. (1990’s): Equivalent response by African-American youth to MST for conduct <=
/span>disturbance and SUD’s.
–
Approaches
to Improve Access to MH Services
for Minority Youth
lEviden=
ce-Base
for Culturally Specific Interventions/
Programs
–TEMAS (Constantino, Malgady, & Rogler; 1994): Culturally sensitive storytelling CBT.
–De Rios (1997): Magical Realism: Cultural intervention =
for traumatized Latino children.
–CMHS System of Care Programs: Those sites rating <=
/span>highest Cultural Competence scores had best outcom=
es for Latino and Af-Am youth.
Interventions
for Minority Families: Evidence-Base
lEvidence-Base for
Culturally Specific Family Interventions
–Brief
Structural/ Strategic Family Therapy (Szapocznik & Santiesteban, 1990’s): Adolescent SUD =
and behavioral problems for Latino and African-America=
n youth/ families.
–McGrogan
(1998): Latino parenting groups, parents with limited literacy.
–Blue-Ban=
ning,
Turnbull, & Pereira (2000). Group action planning (for Latino families & youth w=
ith
DD).
Approaches
to Improve Access to MH Serv=
ices
for Minority Youth
lEviden=
ce-Base
for Culturally Specific Preventive Interventions
for Substance Abuse
–Szapocznik et al. (1980’s): Bicultural Effectiveness Training: Addresses acculturation generational gap=
.
–Ramirez et al. (1999): “Mirame” media and school-<=
/span>based program for SA prevention for Hispanic youth=
.
–Lalonde et al. (1997): TV and storybook novelas fo=
r Latino youth and families for alcohol prevention.
Approaches to Improve Acc=
ess
to MH Services for Minority Youth
lCultural Competence Standards
–Surge=
on
General’s Supplement on Mental Health, Culture, Race, and Ethnicity (establishes need/=
rationale)
–Latino
Behavioral Work Group (WICHE/CMHS)
–Calif=
ornia
Cultural Competence Standards for Managed Mental Health
–CMHS =
Four
Racial/ Ethnic Underserved/ Underrepresented
Populations
–Cultu=
ral
and Linguistic Standards from the Office of Minority Health, U.S.D.H.H.S.
–New Y=
ork
Office of Mental Health Cultural Competence
Indicators (CMHS)
Approaches
to Improve Access to MH Services
for Minority Youth:
CMHS Cultural Competence Stand= ards
CMHS Cultural Competence Stand= ards
lPrinciples
lCultural Competence (Practitioner and System)
lManaged
Care
lCommunity-Based
Systems of Care
lNatural
Supports
lConsumer-Driven
Services
Approaches
to Improve Access to MH Services
for Minority Youth:
CMHS Cultural Competence Standards
CMHS Cultural Competence Standards
lSystems Standards
lCultural Competence Planning
lGovernance
lBenefit Design
lQuality Assurance/ Improvement
lManagement Information Systems
lStaff Training/ Development
lClinical Standards
lAccess
lTriage/ Assessment
lCare Planning
lTreatment Services
lCase Management
lLinguistic/ Communication Support
lDischarge Planning
lSelf-Help
System Standards: Cultural
Competence Planning
lIndividual responsible to leadership accountable f=
or CC
planning.
lPlanning by team representing organization, consum=
ers
and families.
lCC plan should include:
–Proce=
ss for
understanding population (age, gender, ethnicity, SES).
–Proce=
ss for
determining unique regional and ecological variables.
–Staff=
ing
patterns/skills
–Ident=
ification
of appropriate service models.
=
–Ident=
ification
of community resources, strategic alliances, providers.
–Ident=
ification
of natural supports (e.g., healers, churches, community =
organizations).
–Key CC
issues at each level of care (inpatient, outpatient, community-based).
=
;
–Incre=
mental/strategic
approach to CC implementation.
–Rewar=
ds and
sanctions for cultural competence performance.
–Ongoi=
ng
plan maintenance and review.
Overall System Standards: Governance
lCommunity input into RFP & vendor selection=
.
lGoverning board represents consumer population =
and
community.
lFormal grievance procedure with minority commun=
ity/
professional involvement; consumer information in primary
language/dialect at intake and
at time of appeals.
lOmbudsman from community, should not have confl=
icts
of interest.
lGoverning board has final authority over all ap=
peals
and grievances.
lPlan should record and report annually all appe=
als,
grievances, and laws=
uits
by specific provider and ethnicity of complainants.
=
lEquitable percentage of profit reinvested in mi=
nority
community needs.
lPlan addresses needs of sponsored and unsponsor=
ed
populations.
lInteragency agreements to coordinate services w=
ith
other agencies (e.g., public
health, social services, corrections, youth services).
lPractitioner credentialing including cultural
competence standards.
lPolicies on practitioner ethics take into accou=
nt
cultural differences (e.g., =
=
gift giving, social interactions, etc.)
lPlan makes de-listing criteria open for review =
and
accountable for diff=
ering
service needs of diverse populations.
Overall System Standards: Benefit Design
lNo arbitrary restrictions in benefits;
cost-effectiveness by care management.
lPlan ensures comparability of benefits across
populations and age groups.
lCoverage incorporates alternative treatments/
alternative healers and services
by Minority Mental Health Specialists.
lCoverage includes coordination of services acro=
ss
service systems.
lAccess to a full continuum of care, most to lea=
st
restrictive.
lPlan provides information, education, and mater=
ials
to consumers and fam=
ilies
in primary language/dialect through community organizations.
lEligibility criteria defined primarily by behav=
ior
and functioning.
lEligibility determinations by culturally and
linguistically competent staff.
lWritten correspondence on eligibility in consum=
ers'
primary language(s).
lPlan makes provisions in the benefit design for
unsponsored lives and for =
for people who leave the plan.
<=
/span>
lBenefits include a subcapitation approach for
consumers at-risk of multiple,
long-term service needs to ensure intensive services.
<=
span
style=3D'font-size:56%;mso-special-format:lastCR;display:none'>
Overall System Standards: Quality Monitoring and Improvement
lQI indicators applicable to minority population=
s.
lQI program includes representative sampling
approaches.
lFor Plans with limited minority workforces, Min=
ority
Mental Health Specialists =
consult on QI plan development.
=
lSpecial QI studies if irregularities found for
Minority populations.
lAbsence or lower levels of complaints by consum=
ers/
families interpreted as an inadequacy
of the Plan unless shown otherwise.
lConsumer satisfaction surveys translated into l=
ocal
languages and dialects, implemented
by community members independent from the Plan.
lPeriodic assessment of functional outcomes vali=
d and
applicable to minority <=
/span>=
consumers and families, as well as covered mino=
rity
population.
lQI Plan should disaggregate data for minority consumers and families and =
report such data regularly to governing
authority.
lCredentialing and privileging standards for dif=
ferent
disciplines include culturally
and linguistically competent clinical skills, knowledge and attitudes.
=
;
lSufficient Minority Mental Health Specialists t=
o meet
QI goals/ objectives.
<=
span
style=3D'font-size:56%;mso-special-format:lastCR;display:none'>
Overall System Standards: Decision Support and Management Information Systems
lConsumer data should include accurate and
disaggregated coding for gender, ethnicity,
SES, linguistic proficiency and sexual orientation.
lUnified clinical record maintained across all l=
evels
and entire system of care.
lPlan develops database to track minority consum=
ers
across all levels of care.
lEthnicity coding broad and inclusive; capacity =
to
code subgroups, mixed race.
lPlan should track diagnostic and assessment
information, service utilization trends
and patterns across modalities, and behavioral/ functional outcomes.
<=
/b>
lIndividual consumer data confidential, with dat=
a sets
de-identified.
lPlan should track geographically-coded data to =
allow
monitoring of diff=
erential
service utilization and planning across various locales.
<=
/span>
lData findings should be used to continuously as=
sess,
improve and inform strategic
planning for services to minority consumers and families.
<=
/span>
lPlan should require tracking and reporting of
performance data specific to minority consumers and families to governi=
ng
authority for accountability.
l
System Standards: Staff Train=
ing
and Development
lStaff training implemented at all levels,
disciplines, management/ support staff.
lFollowing areas of knowledge, skills, attitudes
essential in continuing education:
oUnderstandi=
ng
cultural differences between different cultural subgroups.
=
oDynamics of
monocultural ("traditional"), acculturating
("transitional"), bicultural and biracial consumers and families.
oUnderstandi=
ng
different, culturally-based folk healing traditions.
oSpecialized
alliance building techniques and culturally acceptable boundary setting.&#=
13;
oTraining in
interdisciplinary team interaction to promote effective care.
oTreatment of
minority sexual minorities, particularly stress of "triple stigma&quo=
t;
(mental