Wicked Problems and Collective Solutions: Addressing Disparities

1
Wicked Problems and Collective Solutions
Addressing Disparities

• Larke Nahme Huang, Ph.D.
• Senior Advisor on Children
• Office of the Administrator
• Substance Abuse and Mental Health Services
  Administration
• Building on Family Strengths
• Research and Services in Support of Children and
  Their Families
• Portland Research and Training Center on Family
  Support and Childrens Mental Health
• Annual Conference
• May 31, 2007

2
Overview

• Stories
• The Demographic Imperative
• Key Findings from National Data
• Wicked Problems
• A Network Structure

3
Stories. in search of happier endings
4
The ChangsCultural Linguistic Barriers to
Negotiating the System

• In Los Angeles, Mr. and Mrs. Changs young adult
  daughter was removed from the home by the police
  when summoned by a neighbor. She had a serious
  emotional disorder with disruptive behaviors that
  the Changs tried to contain within their home,
  not seeking any help.
• With limited English proficiency, they searched
  through all the hospitals in the city trying to
  find her due to privacy regulations, hospitals
  were not allowed to tell them if she had been
  admitted.
• They searched for two weeks before they were told
  to file a missing persons report with the police
  to help locate her.

5
Intoxicado, a 71 million wordLanguage Access
And Availability

• Recently, a Florida hospital was ordered to pay
  71 million in a malpractice suit that left an 18
  year old a quadriplegic, due to the wrong
  interpretation of the word, intoxicadothe
  paramedics took it to mean intoxicated and the
  translation and intended meaning was nauseated.
  Consequently the wrong treatment was given,
  causing the quadriplegia (Armas, 2007)
• A major consequence of a lack of linguistic
  competenceIs this a dramatic example? It may be
  the most costly, but not dramatic, because it
  happens all too often.
• (Ken Martinez, 2007)

6
Seans Story In Need of Appropriate Provider
Intervention and Education

• 17 year old gay youthcame out to mother at age
  14
• Mother had difficulty accepting his sexual
  orientation Sean started acting out, stayed out
  late, arguments with mother, escalating to
  physical conflict, hitting his mother
• After a fight neighbor called police and Sean
  sent to juvenile detention judge sent him to
  foster care group home
• Mother came to terms with his homosexuality,
  but could not get him released from foster care
• Agency increased pressure on Sean to change his
  sexual orientation and restricted contact with
  his mother Sean became depressed
• New probation officer released him to mother
  after 18 months in foster care at cost of 85,000
• (Caitlin Ryan, 2007)

7
Mrs. Moua Incomplete Information and Dangers of
Misdiagnosis

• A Denver social services agency following up on a
  complaint of possible child abuse by a Hmong
  mother of 5 children.
• We conducted a home visit to follow-up on this
  allegation.
• Was this an abusive mother?
• Or, is what you see not always the true reality?
• (DJ Ida, 2007)

8
Red Lake Nation A Dangerous Lack of Resources

• Visit to Red Lake Nation trauma and suicide
  clusters, the aftermath of violent school-based
  shooting
• Serious community concerns about the well-being
  of the children and their fears about returning
  to school
• A 12 year boy, accused of sexually molesting 2 of
  his younger siblings sent from juvenile
  detention to CF services has nowhere to go
• Placed in a homeless shelter off the reservation,
  temporarily

9
Seung Hui ChoThe Virginia Tech University
Tragedy and the Imperative of Engagement

• Seung Hui Cho was a young man with a serious
  emotional disorder.
• Early warning signs, early unusual behaviors were
  noted, family and friends did not turn to the
  mental health system mental health a taboo topic
  within Korean culture
• Brought to the attention of mental health clinic
  then a special justice for commitment hearing
  ordered to involuntary outpatient treatment - yet
  engagement did not occur.

10
So, what do we learn from these stories?

• We have many boundaries to cross
• Chasm between cultures of our diverse communities
  and our helping/care giving systems
• In the continuum of helping relationships,
  beginning with information and awareness -
  engagement - delivery of services, supports -
  follow-up, we have not passed Step 1.
• We need to attach resources and develop
  meaningful partnerships with diverse communities
  to begin to cross these boundaries.

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WHY IS IT IMPORTANT TO CROSS THESE
BOUNDARIES?THE DEMOGRAPHIC IMPERATIVE
12
Minority Population Tops 100 Million (U.S.
Census Bureau, May 17, 2007)

• 1 in 3 US Residents is a minority
• Hispanics largest at 44.3M
• African Americans passed 40M
• Asian American 14.9M
• Native Hawaiian Pacific Islanders reached 1M
• American Indian/Alaska Native 4.5M
• Non-Hispanic Whites 198.7M
• Total US Population 300 M

13
Rates of Change and Implications for Capacity

• Projected Rate of Increase of Youth of Color from
  1995-2015
• African American 19
• American Indian/Alaska Native 17
• Asian American, Native Hawaiian Pacific
  Islanders 74
• Hispanic 59
• Caucasian/White decrease -3

14
Emerging Diverse Populations

• Gay Lesbian Bisexual Youth
• Immigrant Populations

15
Risk Factors for Gay, Lesbian Bisexual Youth

• Higher levels of depression and substance use and
  abuse
• High rates of victimization (also associated with
  depression and suicidality)
• School-based victimization
• 3x more likely threatened with weapon at school
• 2x more likely to have property damaged at school
• Nearly 5x more likely to skip school because felt
  unsafe
• (Ryan and Rivers, 2006)

16
Suicidality and Gay, Lesbian, and Bisexual
Adolescents

• GLB youth 3x more likely to attempt suicide as
  heterosexual youth
• Between 48 - 76 have thought of suicide
  (compared to 19-29 in adolescent populations)
• 29-42 have attempted suicide (compared to 7-13
  in adolescent population)
• Yet, 84 male and 71 female sexual minority
  adolescents report no suicidality at all.
• (Russell and Joyner, 2001)

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GLB Youth of Color

• Challenges of integrating ethnic cultural
  identity with sexual orientation
• Lack of acceptance within racial/ethnic community
• Racism within GLB community
• Further isolation
• (Morrison and LHeureux, 2001)

18
Emerging Populations Immigrants

• Immigrant Households
• Immigrants comprise 12 of the American
  population, and one million new immigrants arrive
  annually.
• Today, 88 of Asian American and 58 of Latino
  American children are growing up in immigrant
  households, and potentially at risk of
  intergenerational conflict.

19
Mental Health and Immigrants

• Immigrants in general appear to have lower rates
  of mental disorders than their US born
  counterparts (50 less in some studies)
• Second and later generations of immigrants have a
  higher risk for mental disorders than their
  parents
• Ex The prevalence of alcohol and other drug
  abuse was more than 4 times higher in US born
  individuals of Mexican descent than those born in
  Mexico (Vega, Kolody, Aguilar-Glaxiola, Alderate,
  Catalana, Carveo-Anduaga, 1998)
• (NSAL and NLAAS Studies in the American
  Journal of Public Health, 2007)

20
Mental Health and Immigrants

• Immigrants increase their risk of mental health
  problems especially if they do not live in native
  ethnic communities.
• The longer an immigrant family lives in the US,
  the worse their prognosis
• (National CoMorbidity Replication Study,
  Kessler et al, 2005)

21
12-Month MH Service Use Among Asian Americans By
Generation (Alegria and Takeuchi, 2007 National
Latino and Asian American Study/ NIMHSAMHSA)
22
Perceived Helpfulness of Care by Nativity
(Alegria Takeuchi, 2007)
23
Perceived Helpfulness of Care by Generation
(Alegria Takeuchi, 2007)
24
Dual Pathways to Care for Youth of Color
25
The Criminalization Of Youth Of Color
(Disproportionality)

• Estimated that 50-75 of youth in detention have
  emotional behavioral disorder
• 73 reported MH problems during screening 57
  previously received MH treatment 55 symptoms of
  depression 50 conduct disorders 50 with MH
  disorder had substance abuse disorder
• The national juvenile justice custody rate for
  youth of color to that for Caucasians was 2.6 to
  1 in 2003
• In 2003, 59,000 youth of color were locked in
  juvenile facilities 61 of total youth in
  custody while they are 1/3 of youth population
• Children and youth of color are being locked up
  at a disproportionate rate and are not being
  treated in the community or in jail
• (Coalition on Juvenile
  Justice, 2000 Snyder, Howard and Sickmund, 2006
  Martinez, 2007)

26
Youth of Color in the Child Welfare System

• Disproportionate 42 of youth are children of
  color in the U.S. yet, 57 in foster care are
  youth of color
• African American children 15 of children in CW,
  but 28 of substantiated allegations of abuse and
  34 of foster care population
• Blacks, Hispanics and Asian/Pacific Islander have
  disproportionate rate of maltx investigations
• African Americans15 of total population under
  18, yet 40 of foster care population
• Uneven treatment at different points in CW system
• Fewer services, plans for family contact, family
  services, and less contact with CW staff
• Placed in out-of-home placement more frequently
  and for longer periods of time.
• (Census Data, 2004, and CWLA,
  2007)

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What does national data tell us about mental
health and substance use issues for diverse youth?
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Major Depressive Episode (MDE) in the Past Year
among Youths Aged 12 to 17, by Race/Ethnicity
2004-2005 (SAMHSA/National Household Survey on
Drug Use and Health NSDUH- 2006)
29
Had at Least One Major Depressive Episode (MDE)
in Lifetime and Receipt of Treatment in the Past
Year for Depression among Persons Aged 12 to 17
by Race/Ethnicity Percentages 2005 (NSDUH)
30
Had at Least One Major Depressive Episode (MDE)
in Past Year and Receipt of Treatment in the Past
Year for Depression among Persons Aged 12 to 17
by Race/Ethnicity Percentages 2005 (NSDUH)
31
Percentages of Youths Aged 12 to 17 Receiving
Alcohol Use Treatment in the Past Year among
Those Who Were Classified as Needing Alcohol
Treatment in the Past Year, by Demographic
Characteristics 2003 and 2004 (NSDUH)
32
Percentages of Youths Aged 12 to 17 Receiving
Illicit Drug Use Treatment in the Past Year among
Those Who Were Classified as Needing Illicit Drug
Treatment in the Past Year, by Demographic
Characteristics 2003 and 2004 (NSDUH)
33
Key Findings

• Variable patterns of major depressive episodes
  and illicit substance abuse among diverse youth
• In all situations, multi-racial youth have among
  the highest rates of MDE and SA
• Significant disparity between need for and
  service utilization across all groups
• Very substantial gap in need and service use
  among American Indians

34
What do we know about co-occurring disorders and
response to interventions among diverse youth?
35
Change in Substance Use Problems Over Time by
Race/Ethnicity Level of Care
Regular Outpatient
Intensive Outpatient
36
Change in Substance Use Problems Over Time by
Race/Ethnicity LOC
Short-Term Residential
Long-Term Residential
37
Preliminary Conclusions

• Racial/ethnic disparities in treatment outcomes
  exist
• Treatment related changes vary by race/ethnicity
  and level of care
• Racial/ethnic disparities are complex --
  different patterns by outcome and by subgroups
  within race/ethnicity
• Over time treatment effects vary by race/ethnicity

38
What About Co-occuring MH and SU Disorders for
Diverse Youth?

• A significant proportion of youth with substance
  use disorders also have co-occurring mental
  health problems
• Although it is unclear which problem predates the
  other, it is clearly recognized that the success
  of treatment depends on the degree to which both
  problems are effectively addressed
• It is also known that there are significant
  racial/ethnic variations in the patterns of
  substance use and co-occurring mental disorders,
  and in access to and outcomes of treatment

39
For Youth in SA Treatment, do overall levels of
internalizing symptoms vary by race/ethnicity?

• Internalizing symptoms depression, anxiety,
  traumatic disorders, suicidality
• Preliminary Findings
• African American youth had lower levels of
  internalizing symptoms than White or Hispanic
  youth
• Dx rates were also lower for African Americans

40
Rates of Major Depression Over Time
41
Rates of Major Generalized Anxiety Disorder Over
Time
42
Rates of Major Suicidal Problems Over Time
43
Research Questions(M. Mulatu and K. Jeffries
Leonard, 2007-Joint Meeting on Adolescent
Treatment Effectiveness, Washington, DC)

• Are there racial/ethnic differences in the degree
  to which substance abuse treatment affects levels
  of co-occurring disorders?
• Can race/ethnic disparities, if any, be
  attributed to differences in levels of care?

44
Do different types of treatment show different
results for diverse youth?
45
Patterns of Changes in Internalizing Symptoms by
Race/Ethnicity and Level of Care
Regular OP
Intensive OP
46
Patterns of Changes in Internalizing Symptoms by
Race/Ethnicity and Level of Care
Medium-Term Residential
Long-Term Residential
47
So, what is our response?
48
National Policy Statements and Presidential
Commissions

• The Surgeon Generals Report
• Mental Health Culture, Race and Ethnicity (2001)
• The Institute of Medicine Report
• Unequal Treatment Confronting Racial Ethnic
  Disparities in Health Care (2002)
• The Presidents New Freedom Commission Report
• Achieving the Promise Transforming Mental
  Health Care in America (2003)
• National momentum for addressing
• disparities in behavioral health care
• proclaim public health imperative

49
Political Will Collective Will

• States
• New Jersey Law requires NJ physicians to take
  cultural competency training to obtain a medical
  license
• Connecticut setting benchmarks for cultural
  competence
• California, Mass, Oregon, Utah state plans for
  cultural competency
• National Organizations
• National Alliance of Multi-Ethnic Behavioral
  Health Associations
• First Nations, NAAPIMHA, NLBHA, NLC
• System Penetration
• Penetration into more child-serving systems
• JJ Disproportionate Minority Confinement
  Equal Justice Initiative
• Penetration into low-capacity, newly emerging
  population areas
• Mental Health Specialty Provider Networks
  (Minnesota)

50
Published Research and Reports on

• Ethnic Minority Mental Health
• Clinical Care with diverse populations
• Cultural Competence
• Risk and Protective Factors for diverse
  communities
• Some, Limited Treatment Effectiveness Studies for
  Diverse Populations
• Child and Youth Development research different
  models of development, including ecological
  approached

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What else do we know?

• In the field, abundance of community practices
  that have worked for diverse groups of
  children, youth, families and adults.
• Culturally-based interventions and approaches
  that are less frequently studied and documented
  (e.g., engagement strategies, cultural brokers,
  promotoras, primary care integration, village
  models, housing project-based care, newcomer
  centers, etc.)
• See focal point Summer 2007

52
Status update?

• We know more than we know
• We share less than we could
• We reinvent, reinvent, reinvent
• We discover the discovered

53
Mental health and substance use disparities are
wicked problems

• Highly complex, intractable social problems
• Messy problems that defy precise definition, cut
  across policy and service areas
• Multiple contributing factors poverty, language
  barriers, structural racism
• Resist solutions offered by the single-agency or
  silo approach
• Traditional ways of working add to the problem by
  further fragmenting services and people

54
Network Structure as a Strategy to Address
Wicked Problems

• Require new ways of working and thinking beyond
  traditional approaches
• Concept of network structure to identify,
  collect, develop innovative solutions for
  communities
• Network structures people actively work together
  to accomplish what they recognize is mutual
  concern

55
3 Characteristics of Network Structures

• 1. Common Mission
• Requires
• seeing the whole picture
• new values, new attitudes
• Expected Outcomes
• Each member see self as one piece of total issue
• See points of convergence, not contention
• Not fighting over scarce resources
• Not wasting time and money

56
Characteristics of Network Structures

• 2. Members are interdependent
• Requires
• Step into others shoes
• It is not what you expect from others, but how
  you understand them
• Expected Outcomes
• Building relationships is primary, tasks are
  secondary
• Connecting existing pockets of trust
• Building trust
• Recognizing expertise of others
• Listening/valuing community experts

57
Characteristics of Network Structures

• 3. Unique structural arrangement
• Composition reps of diverse organizations,
  groups, government, business, community, etc.
• Requires
• Actively doing something
• Members represent own organization and the
  network structure
• Expected Outcomes
• Risk taking proactive
• Innovative ideas emerge
• Visible/invisible conflicts

58
Networks vs Network Structure

• Beyond networking people making connections
  thru meetings and communication technology
• Networks - links among organizations or
  individuals become formalized
• But still working separately

59
Leadership in Network Structures

• Atypical forms of power and authority
• Informal power based on interpersonal relations
  can be more important than formal power
• Modes of leadership rely on role of facilitator
  and broker
• No one in charge
• Rely on exchanges based on interpersonal
  relations rather than contractual arrangements
• Pockets of trust exist before network structure
  is formed
• Success of network structure based on the
  collective orientation
• Culturally different form of leadership and
  authority- soft rather than hard power

60

• National Network to Eliminate Disparities in
  Behavioral Health Care
• Community and Ethnic-Based Organizations and
  Networks
• Knowledge Discovery Centers
• National Facilitating Center

61
National Network to Eliminate Disparities in
Behavioral Health Care (NNED)
Vision All culturally, racially, ethnically
diverse individuals and families live healthy,
thriving lives in supportive communities (draft).
Mission To build and sustain a national
network of diverse racial, ethnic and cultural
communities and organizations to promote
policies, practices, standards and research to
eliminate behavioral health disparities.
62
National Network to Eliminate Disparities in
Behavioral Health CareA SAMHSA-Supported
Initiative

• Key Assumptions
• Around the country, there are pockets of
  excellence in reducing disparities
• There is a wealth of information, insights and
  knowledge that is not be shared
• Research and policy efforts often lack the
  connection to and depth of involvement of the
  very communities they seek to serve
• Lack of coordination of information stymies
  forward movement

63
DESIRED OUTCOMES

• LINKAGES between community providers,
  organizations and networks in diverse communities
  and research/training centers
• IDENTIFY AND LINK POCKETS OF EXCELLENCE
• INFRASTRUCTURE for collecting, analyzing and
  disseminating information, best practice,
  research and policy
• CAPACITY BUILDING through learning
  collaboratives, internet training strategies, and
  community action
• TARGETED ACTIONS through community collaboratives
  to impact disparities

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DESIRED OUTCOMES

• NATIONAL INFLUENCE to focus on elimination of
  disparities
• COORDINATED RESPONSES for recommended policy,
  practice and research direction to the field
• COMMUNITY SYSTEM CHANGE through changes in
  knowledge, attitudes, behaviors of individuals
• BEHAVIORAL HEALTH DISPARITY ELIMINATION to ensure
  access to and availability of culturally
  appropriate, high quality, results-producing
  care.

65
National Network to Eliminate Disparities in
Behavioral Health Care
STRUCTURE
The NNED structure consists of three interlocking
entities.
Community and Ethnic-Based Organizations and
Networks
Knowledge Discovery Centers
National Facilitating Center
66
National Network to Eliminate Disparities in
Behavioral Health Care
STRUCTURE

• Define and document problems and solutions
• Promote new perspectives
• Exchange and share information peer to peer
  technical assistance
• Create opportunities for community partner
  involvement

Community and Ethnic-Based Organizations
Networks
67
National Network to Eliminate Disparities in
Behavioral Health Care
STRUCTURE

• Redevelop frameworks for research on disparities
• Research community-defined best practices
• Provide TA and consultation
• Support a community of learners
• Engage communities in partnership

Knowledge Discovery Centers
68
National Network to Eliminate Disparities in
Behavioral Health Care
STRUCTURE

• Develop and maintain a network infrastructure
• Identify and link entities
• Share information and disseminate knowledge
• Coordinate, track, monitor NNED projects
• Implement NNED communication strategy
• Provide TA/Training Vehicles
• Website
• Develop/Implement Funding Plan

National Facilitating Center
69
Priority Areas
National Network to Eliminate Disparities in
Behavioral Health Care

• Community-defined Evidence Models to Measure
  Practice Effectiveness (inventory of effective,
  community-based practices criteria for
  community-defined evidence, etc.)
• Anti-Stigma and Behavioral Health Education
  Campaigns for Diverse Groups (Ad Council and
  diverse community leaders to develop culturally
  appropriate messages and vehicles and strategies
  for better reaching diverse communities)
• Community Engagement Models
• Workforce Development
• Integration of Health/Behavioral Health

70
Pockets of Excellence to disseminate and
promote uptake

• Re-arraying Services
• Community Engagement Community Health Care
  Workers
• Asian Counseling and Referral Services The
  Village Project
• Systems Change
• Child Welfare Disparity Reduction
• Juvenile Justice Reducing Disproportionate
  Minority Confinement

71
And more..

• Child Family Interventions
• Indian Country Trauma Center Cultural
  Adaptations of Interventions
• Focal Point Effective Interventions for
  Underserved Populations, summer 2007
• Training and Workforce
• HBCU Coordinating Center at Morehouse University
  workforce training
• And on and on..

72
A Health Example Tuberculosis Community-based,
Cultural Case Manager Model
(Chaulk, 2004)

• Builds on the local knowledge of the target
  neighborhood.
• Views cultural competence as not just skin color
  or language fluency
• Interpreters as mediators most effective.
• Relies on Neighborhood Health Messengerstrusted
  , credible people from the communitywho can
  translate information into and out of the
  neighborhood (two-way flow of information) and
  help bridge the worlds of vulnerable families and
  public systems
• Incorporates team orientation with communities
  and community residents--not just doctors and
  nurses seen as experts.

73
Traditional TB Clinic Model
TB Clinic
TB Clinic
TB Clinic
Client
Client
Client
At 3 Months
At 6 Months
At 9 Months
Intensity of Social Networks
Primary care
Housing
Primary care
Primary care
TB Clinic
TB Clinic
Social
TB Clinic
Social
Social
Phone 48
Client
Client
Trans.
Client
Phone 72
Housing
Work
School
Phone 24
Housing
6 home visits
3 home visits
9 home visits
School
School
Housing
Cultural Case Manager Model
74
Therapy completion rates (96-98 vs. 99-01)
N 319
75
Therapy acceptance rates (96-98 vs. 99-01)
N 389
76
Ex Disparity Reduction for Children of Color in
Child Welfare (Redd, Bell, et al, 2005)

• Reducing the number of African American Children
  in Child Welfare in 2 cities in Illinois removal
  of child from home.
• Removal rate in two counties 24/1000 and
  23/1000 overall rate of removal was 4.3/1,000
• Strategy combine business principles with
  cutting edge behavioral intervention research
• Implemented
• Assessment of service environment contextual
  factors
• Develop sound business plan that includes QA, use
  of data, analysis of decision-making points
• Improve quality of existing services
• Introduce new community-based leadership group
• 3rd Year of Intervention Base rates for removal
  of African American youth had decreased by more
  than 50 (from 24/1000 to 11/1000)

77
Targeting Disproportionality in Juvenile Justice
(Burns Institute Casey Foundation, JDAI,
2002)

• Juvenile Detention Alternatives Initiative
  communities develop alternatives to detention
  without jeopardizing safety of community
• Risk Assessment Instrument remove bias
• Obtain data at every step of the way ? pinpoints
  what actions are considered, identify where along
  continuum of care that disparate decisions were
  being made ? discuss with staff
• Review decisions of intake staff by looking at
  disposition rates for diverse youth feedback to
  staff

78
Targeting Disproportionality in Juvenile Justice
Results

• Once we had real data, we were able to move from
  anecdotal information to data-based strategies,
  because now we knew how real the problem was
  Judge Bergman
• Results
• Gap between white and youth of color in
  likelihood of being detained decreased
• For African American and Latino youth number
  admitted to detention dropped by half.

79
Results Proportion of Delinquency Referrals
Resulting in Detention by Race/Ethnicity

(Casey, JDAI, 2002)
80
Integration Co-Location of Mental Health and
Primary Care

• Primary Care Centers
• HRSA Community Collaboratives
• Depression Collaborative
• Family Resource Centers
• Westchester Family Health Centers Latino mental
  health screening
• Urban Mental Health Initiatives Richmond, Miami
• Community Resource Centers
• Asian Counseling Referral Center Village
  Project
• School-based Health Centers
• Dallas School-based clinics improved outreach
  and care to students of color
• Native American youth engage in interventions
  for substance use and suicide prevention when
  offered in schools and provided to all students,
  minimizing stigmatization of at-risk youth

81
Culturally-Based Behavioral Health Interventions

• The Miami Group Szapocznik Collaborators
• 3 decades work with poor, inner city Hispanic and
  African American families
• Adapted and further developed interventions based
  on cultural values (structural and strategic
  family therapy)
• Keep refining interventions to population needs
  and changing cultural context
• Studies to examine generalizability to other
  ethnic groups
• Developed empirically supported treatments using
  ethnic minority groups
• Ongoing work design flexible manuals to tailor
  interventions to specific life situations,
  culture-related stressors
• (Bernal, G., 2006 Muir, Schwartz Szapocznik,
  2004)

82
Cultural Adaptations to Behavioral Health
Interventions Cognitive Behavioral Therapy

• Modifying concepts thought stoppage vs. leave
  bad thoughts at the door (Native American
  adaptation)
• School-based CBT for anxiety in low-income
  African American teens in manualized protocol
  included experiences that these teens would
  encounter, neighborhood crime, violence, issues
  related to kinship care decreased anxiety
  symptoms (Ginsburg Drake, 2002)
• Evidence that culturally sensitive CBT can be
  successful with youth from diverse backgrounds
  for treatment of depression and anxiety (Mirande
  et al, 2005)

83
Cultural Adaptations to Behavioral Health
Interventions Parent-Child Interaction Therapy

• Parent Child Interaction Therapy (PCIT)
• Oklahoma Group Delores BigFoot, Indian Country
  Child Trauma Center (2006)
• Aligning Native American cultural values re
  honoring children and importance of relationships
  (attachment theory)
• Modifying concepts and terms
• San Diego Kristin McCabe et al (2004)
• Reframe intervention as educational vs.
  therapeutic
• Teacher/expert vs. therapist
• Comprehensive engagement protocol incorporate
  extended family members, removal of barriers to
  treatment

84
SAMHSA Cultural Competence and Disparities
Roadmap

• CCED Matrix Work Group internal and external
  processes
• External Activities
• Public Education and Information Campaign
  Tailored for 4 Racial Ethnic Communities
• Workshops and Town Halls American Indian/
  Native Hawaiian and Pacific Islanders
• Support of the NNED
• Internal Activities
• Examination of Grants Solicitation and Review
  Process (e.g. Tribal input)
• Inventory of CCED-focused projects, products and
  initiatives
• Internal Professional Development and Training on
  CCED
• Better coordination among the 3 Centers and the
  Offices

85
There is hope for, as a collective,

• We are ready to identify and capitalize on good
  work being done and to support families and youth
  to strengthen their familial, cultural, ethnic,
  racial, linguistic connections so that families
  find solutions and not systems!
• We are ready to walk in the diverse worlds of
  performance measurement, data for continuous
  quality improvement and accountability and
  ethnographic and personal stories.
• We are ready to build our community and
  professional relationships in a concerted effort
  to ensure that all children and families have
  hope and opportunity for fulfilling lives in safe
  and supportive communities.

86
Acknowledgements

• Rosalba Garcia
• Ken Martinez, PsyD
• David Takeuchi, Ph.D.
• Kimberly Jeffries Leonard, Ph.D.
• Mesfin Mulatu, Ph.D.
• Beatrice Rouse, Ph.D.
• DJ Ida, Ph.D.
• Myia Holmes
• Caitlin Ryan, Ph.D.
• PJ Rivera
• Gail Ritchie, MSW