7. Cultural Competence in Serving Children and Adolescents with Mental Health Problems

All cultures practice traditions that support and value their children and prepare them for living in their society. This way, cultures are preserved for future generations.

Culturally competent mental health service providers and the agencies that employ them are specially trained in specific behaviors, attitudes, and policies that recognize, respect, and value the uniqueness of individuals and groups whose cultures are different from those associated with mainstream America. These populations are frequently identified as being made up of people of color—such as Americans of African, Hispanic, Asian, and Native American descent. Nevertheless, cultural competence as a service delivery approach can be applied to systems that serve all persons, because everyone in the society has a culture and is part of several subcultures, including those related to gender, age, income level, geographic region, neighborhood, sexual orientation, religion, and physical disability.

Culturally competent service providers are aware and respectful of the importance of the values, beliefs, traditions, customs, and parenting styles of the people they serve. They are also aware of the impact of their own culture on the therapeutic relationship and take all of these factors into account when planning and delivering services for children and adolescents with mental health problems and their families.

In a “System of Care,” local organizations work in teams—with families as critical partners—to provide a full range of services to children and adolescents with serious emotional disturbances. The team strives to meet the unique needs of each young person and his or her family in or near their home. These services should also address and respect the culture and ethnicity of the people they serve.

Goals and Principles of Cultural Competence

Culturally competent “systems of care” provide appropriate services to children and families of all cultures. Designed to respect the uniqueness of cultural influences, these systems work best within a family’s cultural framework. Nine principles govern the development of culturally competent programs:

• The family, however defined, is the consumer and usually the focus of treatment and services.
  
  
• Americans with diverse racial/ethnic backgrounds are often bicultural or multicultural. As a result, they may have a unique set of mental health issues that must be recognized and addressed.
  
  
• Families make choices based on their cultural backgrounds. Service providers must respect and build upon their own cultural knowledge as well as the families’ strengths.
  
  
• Cross-cultural relationships between providers and consumers may include major differences in world views. These differences must be acknowledged and addressed.
  
  
• Cultural knowledge and sensitivity must be incorporated into program policymaking, administration, and services.
  
  
• Natural helping networks such as neighborhood organizations, community leaders, and natural healers can be a vital source of support to consumers. These support systems should be respected and, when appropriate, included in the treatment plan.
  
  
• In culturally competent systems of care, the community, as well as the family, determine direction and goals.
  
  
• Programs must do more than offer equal, nondiscriminatory services; they must tailor services to their consumer populations.
  
  
• When boards and programs include staff who share the cultural background of their consumers, the programs tend to be more effective.

Ideally, culturally competent programs include multilingual, multicultural staff and involve community outreach. Types of services should be culturally appropriate; for example, extended family members may be involved in service approaches, when appropriate. Programs may display culturally relevant artwork and magazines to show respect and increase consumer comfort with services. Office hours should not conflict with holidays or work schedules of the consumers.

Developing Cultural Competence

Although some service providers are making progress toward cultural competence, much more needs to be done. Increased opportunities must be provided for ongoing staff development and for employing multicultural staffs. Improved culturally valid assessment tools are needed. More research will be useful in determining the effectiveness of programs that serve children and families from a variety of cultural backgrounds.

For many programs, cultural competence represents a new way of thinking about the philosophy, content, and delivery of mental health services. Becoming culturally competent is a dynamic process that requires cultural knowledge and skill development at all service levels, including policymaking, administration, and practice. Even the concept of a mental disorder may reflect a western culture medical model.

At the Policymaking Level
Programs that are culturally competent:

• appoint board members from the community so that voices from all groups of people within the community participate in decisions;
  
  
• actively recruit multiethnic and multiracial staff;
  
  
• provide ongoing staff training and support developing cultural competence;
  
  
• develop, mandate, and promote standards for culturally competent services;
  
  
• insist on evidence of cultural competence when contracting for services;
  
  
• nurture and support new community-based multicultural programs and engage in or support research on cultural competence;
  
  
• support the inclusion of cultural competence on provider licensure and certification examinations; and
  
  
• support the development of culturally appropriate assessment instruments, for psychological tests, and interview guides.

At the Administrative Level
Culturally competent administrators:

• include cultural competency requirements in staff job descriptions and discuss the importance of cultural awareness and competency with potential employees;
  
  
• ensure that all staff participate in regular, inservice cultural competency training;
  
  
• promote programs that respect and incorporate cultural differences; and
  
  
• consider whether the facility’s location, hours, and staffing are accessible and whether its physical appearance is respectful of different cultural groups.

At the Service Level
Practitioners who are culturally competent:

• learn as much as they can about an individual’s or family’s culture, while recognizing the influence of their own background on their responses to cultural differences;
  
  
• include neighborhood and community outreach efforts and involve community cultural leaders if possible;
  
  
• work within each person’s family structure, which may include grandparents, other relatives, and friends;
  
  
• recognize, accept, and, when appropriate, incorporate the role of natural helpers (such as shamans or curanderos);
  
  
• understand the different expectations people may have about the way services are offered (for example, sharing a meal may be an essential feature of home-based mental health services; a period of social conversation may be necessary before each contact with a person; or access to a family may be gained only through an elder);
  
  
• know that, for many people, additional tangible services—such as assistance in obtaining housing, clothing, and transportation or resolving a problem with a child’s school—are expected, and work with other community agencies to make sure these services are provided;
  
  
• adhere to traditions relating to gender and age that may play a part in certain cultures (for example, in many racial and ethnic groups, elders are highly respected). With an awareness of how different groups show respect, providers can properly interpret the various ways people communicate.

Achieving Cultural Competence
To become culturally competent, programs may need to:

• assess their current level of cultural competence;
  
  
• develop support for change throughout the organization and community;
  
  
• identify the leadership and resources needed to change;
  
  
• devise a comprehensive cultural competence plan with specific action steps and deadlines for achievement; and
  
  
• commit to an ongoing evaluation of progress and a willingness to respond to change.

Important Messages About Children's and Adolescents' Mental Health:

• Every child’s mental health is important.
  
  
• Many children have mental health problems.
  
  
• These problems are real and painful and can be severe.
  
  
• Mental health problems can be recognized and treated.
  
  
• Caring families and communities working together can help.
  
  
• Information is available; call 1.800.789.2647.

The fact sheet is based on a monograph, Towards a Culturally Competent System of Care, authored by Terry L. Cross, Karl W. Dennis, Mareasa R. Isaacs, and Barbara J. Bazron, under the auspices of the National Technical Assistance Center for Children’s Mental Health at Georgetown Universty in Washington, D.C., and funded by the National Institute of Mental Health (1989).