Lindsay E. Holly Amanda Chiapa Armando A. Pina

1. Chapter 4: Evidence-Based Treatments for Mental, Emotional, and Behavioral Problems in Ethnic Minority Children and Adolescents Lindsay E. Holly Amanda Chiapa Armando A. Pina

2. Ethnic Minority Youths • Minority youths comprise a significant proportion of the nation’s existing and growing population • Youth estimates from U.S. Census Bureau (2010) • 18 million Hispanic/Latino • 12 million African American • 3 million Asian American • 1 million Native American • U.S. census estimates significant increase over time • Relatively little known about efficacy of EBT in minorities

3. Key Terms • Culture: group of people’s shared history, values, norms, goals, and practices that are transmitted from generation to generation through social interactions • Subcultures: smaller, more homogeneous groups that make up the larger cultural or ethnic group • Often have unique cultural experiences that differentiate them from other groups within the same ethnicity

4. Cultural Consideration in Treatment Modification • Cultural attunement: process by which culturally relevant treatment elements are added to previously existing treatment protocol in order to enhance treatment engagement and retention of a specific ethnic minority group (Falicov, 2009) • E.g., using bilingual therapists • Cultural tailoring: individualized approach to modifying existing treatment protocols • E.g., collect information about the client’s personal connection to his or her cultural background in relation to the targeted therapeutic goal • Cultural adaptation: the systematic modification of an EBT protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values

5. Evidence for Using Current Treatment Protocols • Encouraging evidence supporting the use of certain procedures for targeting anxiety, depression, disruptive disorders, and ADHD • Most studies provide robust evidence for symptom reductions for Hispanic/Latino and African American youths at levels similar to Caucasian youths • Approximately half of studies relied on standard treatment protocols while the other half relied on treatments with at least some cultural consideration in program design/implementation

6. Adapting Treatments • Therapists were sensitive to the targeted culture by providing treatment in the client’s native language • Therapists were also charged with learning and understanding fundamental cultural values, norms, and customs associated with the client’s ethnic background • This knowledge was incorporated into the treatment protocol for delivery • E.g., Silverman et al. (1999) trained clinicians in Hispanic and Caribbean conceptualizations of anxiety and coping styles

7. Culturally Relevant Add-Ons • Add-ons areused to accomplish cultural attunement • Add-ons involve incorporating culturally salient themes or elements into the treatment • E.g., Szapocznik et al. (1989): included Bicultural Effectiveness Training into the standard Family Effectiveness Training protocol in their treatment of disruptive disorders in Hispanic/Latino youths • Culturally attuned materials are helpful in improving treatment engagement

8. Cultural Attunement: African Americans • Typically focus on contextual experiences that occur within the immediate ecological framework • E.g., Ginsburg and Drake (2002): incorporated specific examples of stressors often faced by low-income African American communities into their standard CBT protocol for youths with anxiety • Despite variability in the degree and manner of culturally sensitive modifications, each of the identified culturally attuned treatments was found to be effective in improving targeted outcomes (i.e., anxiety, depression, disruptive behaviors) in ethnic minority youths.

9. Studies Without Cultural Considerations • See similar improvements to studies with cultural considerations/modifications • May be the case that the extent to which cultural considerations should be applied to current treatments varies as a function of unexamined factors that may or may not be linked to ethnic background • E.g., socioeconomic status, acculturation level

10. Integrating Culture in Treatment • Despite promising effects of using current EBTs in ethnic minorities, there is evidence to suggest treatment efforts need to be strengthened • Appears to be true particularly with African American children • Literature is limited, however, and studies often lack adequate statistical power • Findings cannot be considered to be robust across cultures and subcultures since research has mainly focused on African American and Hispanic/Latino youths

11. Theory-Based Approaches • Three important questions: • Do current EBTs need to be modified for use with ethnic minority youths? • What elements of EBTs should be modified for ethnic minority youths? • For whom (what subgroups of ethnic minority youths) should EBTs be modified? • Current literature suggests that cultural modifications are warranted

12. Treatment Models • Designed to guide a clinician or researcher through the process of culturally adapting a standard EBT • Core concept in models: combining both theory and data to determine whether a cultural adaptation is needed and what components should be adapted • Caution is suggested for haphazardly modifying all EBTs for all ethnic minority clients, instead, use selective and directed modification strategies (Lau, 2006)

13. Cultural Modification • Cultural modification may be warranted if there are: • 1) Group-specific risk and resilience processes that influence the development, maintenance, and/or amelioration of the targeted clinical problem • 2) Group-specific characteristics that might limit engagement in the particular treatment protocol • If modifications are merited, use data to establish and design the specific treatment modifications based on the identified group-specific qualities

14. Treatment Parameters • Adaptation can happen on two levels: 1) surface structure and 2) deep structure (Resnicow et al., 1999, 2000) • Surface structure: Adaptations focus on adjusting treatment materials and messages to be consistent with and relevant for the targeted minority group • Consistent with cultural attunement • Ensures feasibility of the modified EBT • Deep structure: Determines program impact by focusing on making the treatment salient to the target group • Requires thorough understanding of the group’s cultural values, norms, and stressors (e.g., historical, environmental, social, economic) • May be necessary to successfully reach certain populations of minority youths

15. Conclusions • Theory and research relevant to treatment of ethnic minority youths is a growing body of empirical work • Some current EBTs are successful in reducing symptoms and disorder rates in Hispanic/Latino and African American youths • Lack of sufficient evidence to indicate whether current treatment protocols should be modified for use with ethnic minority youth, if treatment elements should be modified, and for whom modifications are necessary

16. Clinical Recommendations • Clinicians need to stay abreast of empirical advancements in EBTs with minority populations and utilize cultural modifications when there is evidence to do so • Standard ETBs should be implemented with an awareness of and sensitivity to cultural background of the individual client • Awareness includes: knowledge of cultural characteristics, clinicians’ own preconceived notions related to ethnic groups, and increasing their level of cultural competence