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 Children�s 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 In my current job, I travel more than in previous work; I hear stories that are exhilirating and stories that are appalling. I have the opportunity to visit agencies and communities around the country. I see exciting, innovative work in children�s mental health. Some of the most compelling stories are those of children and families who are not in the mainstream, the families we considered underserved and not engaged or struggling. I continue to see the persistent chasm between our caregiving systems and the cultures of these families.In my current job, I travel more than in previous work; I hear stories that are exhilirating and stories that are appalling. I have the opportunity to visit agencies and communities around the country. I see exciting, innovative work in children�s mental health. Some of the most compelling stories are those of children and families who are not in the mainstream, the families we considered underserved and not engaged or struggling. I continue to see the persistent chasm between our caregiving systems and the cultures of these families.

4. The Changs:Cultural & Linguistic Barriers to Negotiating the System In Los Angeles, Mr. and Mrs. Chang�s 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.

6. Sean�s Story: In Need of Appropriate Provider Intervention and Education 17 year old gay youth;came 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 Cho:The 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.�

11. 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)

17. 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 L�Heureux, 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)

24. Dual Pathways to Care for Youth of Color

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 Americans=15% 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)

27. What does national data tell us about mental health and substance use issues for diverse youth?

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?

44. Do different types of treatment show different results for diverse youth?

47. So, what is our response?

48. National Policy Statements and Presidential Commissions The Surgeon General�s Report: Mental Health: Culture, Race and Ethnicity (2001) The Institute of Medicine Report: Unequal Treatment: Confronting Racial Ethnic Disparities in Health Care (2002) The President�s 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

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

51. 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. We know more than we know We share less than we could We reinvent, reinvent, reinvent� We discover the discovered Status update?

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

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

62. National Network to Eliminate Disparities in Behavioral Health Care:A 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. 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 DESIRED OUTCOMES

64. 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.

69. Priority Areas 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��..

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.

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