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Pathways to Cultural Competence: Assessing and Treating Latino Children and Families Affected by Tra

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Title: Pathways to Cultural Competence: Assessing and Treating Latino Children and Families Affected by Tra


1
Pathways to Cultural Competence Assessing and
Treating Latino Children and Families Affected by
Trauma Using the TAP Model
  • Lisa Conradi, Psy.D. and Clorinda Merino, M.Ed.
  • Chadwick Center for Children Families
  • Rady Childrens Hospital, San Diego
  • A presentation at the
  • 17th National Conference on Child Abuse and
    Neglect
  • Thursday, April 2, 2009

2
Goals and Objectives of Presentation
  • Participants will be able to describe the Trauma
    Assessment Pathway (TAP) framework for working
    with complexly traumatized children and families
  • Participants will be able to describe how to
    conduct a culturally sensitive and appropriate
    assessment with Latino children and families
  • Participants will understand the rationale for
    adapting clinical practices to fit the needs of
    Latino families.
  • Participants will be able to describe ways that
    mental health providers can adapt their practices
    to better serve Latino families.

3
TAP Model
  • A treatment manual for traumatized children ages
    2 to 18 years
  • Incorporates assessment data, clinical interview,
    and observation to create a Unique Client Picture
  • Includes specific components of trauma-specific
    treatment described by the Trauma Wheel
  • Draft of manual available on Chadwick Center TAP
    website (www.taptraining.net)
  • Online version of TAP Training in development and
    will be completed by June 2009 (www.taptraining.ne
    t)

4
TAP Model Overview
  • TAP provides a framework to increase the capacity
    for sites to build and sustain an
    assessment-based treatment program.
  • TAP can help sites incorporate and integrate
    existing appropriate evidence-based treatment
    services into their program.
  • For complicated and complexly traumatized
    children, TAP provides a guide for individualized
    trauma treatment.

5
Three Components of TAP
  • Assessment creating the Unique Client Picture
  • Triage
  • Treatment

6
Trauma Assessment Pathway Model (TAP) At a
Glance
Initial Screening Process
ASSESSMENT
Refer out, if necessary
Triage
Assessment Clinical Interview and Standardized
Measures
Integrate Assessment Information Form Unique
Client Picture
Narrow the Clinical Focus
Select Symptom Domains Hypotheses/Prioritize
TRIAGE
Identify Appropriate Treatment
(AND/OR) Refer to Evidence-supported TAP
Treatment Model
Refer to a specialized program if needed
TREATMENT
Establish Treatment Goals

Treatment Pathway Guides treatment decisions and
the use of the Trauma Wheel
Trauma Wheel
Reassessment
Continue Treatment Following the Treatment Pathway
Termination
7
Why Attend to Culture?
  • Ethnic minority groups continue to grow and
    diversify, in terms of countries of origin and
    geographic distribution in the US.
  • Currently, the Latino population is the largest
    ethnic minority population (13.1 Census 2006)
  • Continues to be the fastest growing ethnic
    minority group
  • Widespread distribution of the Latino population
    across the US (e.g., South, Midwest)
  • Standard interventions may not be sufficient or
    appropriate.

8
Why Attend to Culture?
  • Latinos are over-represented among families
    living in poverty (Kaiser Family Foundation,
    2004).
  • Latinos are thus more vulnerable to risk factors
    (low income, teen parenting, lack of health
    insurance) that contribute to parenting stress
    and child abuse (Kaiser Family Foundation, 2004).
  • Institutions have treated Latinos and other
    minority groups in ways that have aroused
    suspicion and resentment.
  • Families may be more suspicious of serving
    systems due to fears of the system in general,
    due to lack of documentation, etc.
  • These factors contribute to lower service
    utilization among Latinos they are
    underrepresented in all sectors of care,
    including child welfare and mental health (Bui
    Takeuchi, 1992 McCabe et al., 1999).
  • We live in a multicultural society and this
    diversity enriches all of us

9
Adaptation Guidelines for Serving Latino
Children and Families Affected by Trauma
Project Overview
  • Goal Create Resource Guidelines for Serving
    Latino Children and Families Affected by Trauma.
  • Conducted four local and national focus groups in
    order to determine priority areas that should be
    the focus of the Guidelines.
  • Created a Steering Committee of national experts
    to oversee the creation of Priority Area
    Templates.
  • Priority Area Templates combined to create the
    overall Guidelines.
  • Guidelines designed to be a resource for anyone
    who works with Latino families from direct
    service providers to administrators and policy
    makers.
  • Available online at www.chadwickcenter.org/WALS.h
    tm

10
Identified Priority Areas
  • Assessment
  • Provision of Therapy
  • Communication and Linguistic Competence
  • Cultural Values
  • Immigration and Documentation
  • Child Welfare/Resource Families
  • Service Utilization and Case Management
  • Diversity Among Latinos
  • Research
  • Therapist Training and Support
  • Organizational Competence
  • System Challenges and Policy

11
WALS Steering Committee Members
  • Diversity Among Latinos - Clorinda Merino, MEd,
    Chadwick Center for Children and Families, Rady
    Childrens Hospital, San Diego
  • Research - Kristen McCabe, PhD, University of
    California, San Diego, Child and Adolescent
    Services Research Center, Rady Childrens
    Hospital, San Diego
  • Therapist Training and Support - Carmen Ortiz
    Hendricks, DSW, ACSW, LMSW, Yeshiva University
  • Organizational Competence - Ken Martinez, PsyD,
    Technical Assistance Partnership, American
    Institutes for Research and Ernestine
    Briggs-King, PhD, Duke University School of
    Medicine, the National Center for Child Traumatic
    Stress and the Center for Child and Family Health
  • System Challenges and Policy - Lisa Conradi,
    PsyD, Chadwick Center for Children and Families,
    Rady Childrens Hospital, San Diego
  • Assessment - Carla Danielson, PhD, National Crime
    Victims Center, Medical University of South
    Carolina
  • Provision of Therapy - Michael de Arellano, PhD,
    National Crime Victims Center, Medical University
    of South Carolina
  • Communication and Linguistic Competence - Luis E.
    Flores, MA, LPC, LCDC, RPT-S, Serving Children
    and Adolescents in Need, Inc. (SCAN)
  • Cultural Values - Magdalena Perez, PhD, I3
    Research
  • Immigration/Documentation - Susana Rivera, PhD,
    Serving Children and Adolescents in Need, Inc.
    (SCAN)
  • Child Welfare/Resource Families - Jorge Cabrera,
    MSW, ACSW, Casey Family Programs, San Diego Field
    Office
  • Service Utilization and Case Management - Ana
    Bridges, PhD, University of Arkansas

12
Organization of Templates
  • Four pages allocated per priority area. Cover
    the following topics
  • Background of the Problem
  • Statement of the Problem
  • Recommendations from the Field
  • Recommendations on Promoting Resilience in this
    priority area
  • Recommendations on Partnering with Youth/Families
    in this priority area
  • Community Examples/Best Practices
  • Resources to learn more about this priority area
  • Final product designed to be viewed either in its
    entirety or by individual priority area.

13
Assessment
  • To get the full Unique Client Picture
  • gather information via
  • Clinical Interviews
  • Behavioral Observation
  • Standardized Measures

14
Client Assumptions
  • What are some basic assumptions you may have
    about traumatized clients?
  • How have you validated those assumptions?

15
Assessment Pathway Process
  • Core measures administered
  • Problem areas identified
  • Other measures are administered to probe more
    deeply

16
Guiding Therapists via Assessment
Pathways integrated into assessment measures
17
Critical Items
18
Procedures for Assessment with Standardized
Measures
  • Administration
  • Client feedback
  • Interpretation
  • Treatment planning

19
Assessment Statement of the Issue
  • A number of guidelines emphasize the importance
    of considering the cultural context within which
    the family exists and adapting the approach to
    treatment with these families accordingly (e.g.,
    Santiago-Rivera, Arredondo, Gallardo-Cooper,
    2002 Vera, Vila, Alegr?a, 2003).
  • The need for modifications to standard assessment
    practices is highlighted by the growing
    population of ethnic groups in the U.S., and the
    potentially heightened vulnerability of these
    groups to certain traumatic events.
  • In a culturally appropriate trauma-informed
    assessment, one needs to address a family's
    preferred language, cultural beliefs, current
    community, social support system, socioeconomic
    status, preconceived notions about mental health
    treatment, and specific trauma history.

20
Assessment Selected Recommendations
  • Investigate the intended population
  • Learn about the intended culture through a
    variety of resources in order to know what
    clinical questions must be asked in a trauma
    assessment and how to ask such questions
  • Navigate new ways of delivering assessment
    services
  • Modifying assessment delivery to better
    accommodate individual needs and characteristics
    of population
  • Overcoming obstacles such as distrust of
    providers, language barriers, and logistical
    barriers
  • Further assess caregiver extended family members,
    and other collaterals

21
Assessment Selected Recommendations, Contd
  • Organize background assessment to better
    accommodate intended population.
  • Include social, educational, legal, and medical
    and mental health history
  • Understanding the family's cultural context helps
    guide interview questions about potential
    background events
  • Recognize and broaden the range of traumatic
    events to be assessed.
  • Questions should be behaviorally specific in
    order to increase the validity of the assessment
    (Resnick et al., 1993
  • Assess for trauma in country of origin,
    immigration trauma, discrimination, etc.
  • Incorporate the use of cultural measures into
    your assessment process.

22
How to Form Your Clinical Hypothesis
  • Consider all assessment feedback
  • Determine the Unique Client Picture
  • Which family members need to be included in
    treatment? What are the dynamics in the family?
  • Family and client buy in
  • Consider the cause of distress

23
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24
Treatment goals are written at this stage and
will reflect
  • Symptoms to be reduced or eliminated
  • Safety and risk issues
  • Treatment objectives
  • Trauma resolution
  • Clinical Hypotheses

25
What if your client has complex trauma and
doesnt fit neatly into any particular treatment
model?
  • …Triage into the TAP treatment component.

26
TAP Treatment Component
  • TAP incorporates several Common Fundamental
    Components of Trauma Treatment into the Trauma
    Wheel.
  • Developmental Issues
  • Cultural Issues
  • Therapeutic Relationship
  • Systemic and Attachment Issues
  • Behavioral Problems
  • Cognitive Distortions
  • Making Sense of the Trauma
  • Relationship Building, Child Development and
    Culture hold the wheel together and play a key
    role in understanding the child.
  • Berliner, 2005 Lieberman, 2005 Taylor et al.,
    2005

27
TAP Treatment Component Theoretical Influences
  •  Developmental theory
  • Attachment theory
  • Neuropsychological/Biopsychological theory
  • Cognitive theory
  • Behavioral theory
  • Family systems theory
  • Person-centered theory

28
The Trauma Wheel
Relationship Building
Addressing Maladaptive Cognitions
Affect Regulation
Systemic Dynamics
Child Development
Skill Building Psychoeducation
Trauma Integration
Culture
29
Heuristics of Using The Clinical Pathway
  • One skill builds upon another.
  • All spokes of the Trauma Wheel will be addressed
    at some point during treatment.
  • The length of time and intervention type depend
    upon the unique client picture.
  • The wheel is fluid you move back and forth
    between spokes of the wheel.

30
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31
Provision of Therapy Statement of the Issue
  • In a national sample of children affected by
    trauma, the NCTSN (2005) found that Latino
    children were at greater risk for certain types
    of trauma than Caucasian children, including
    exposure to domestic violence, impaired
    caregiver, and community violence.
  • Unfortunately, Latino children tend to
    underutilize mental health services (Hough et
    al., 1987), including being at greater risk for
    premature termination (Sue, Fujino, Hu, Takeuchi,
    Zane, 1991), and have limited access to
    culturally appropriate services (Acosta, 1979
    Young, Klap, Sherbourne, Wells, 2001).
  • Research on the efficacy of evidence-based
    treatments with Latinos/Hispanics has been
    scarce, and Latinos/Hispanics may not have access
    to best practices in the field of trauma
    treatment.
  • Guidelines that focus on increasing access and
    quality of trauma-informed mental health services
    for Latino/Hispanic children and families, as
    well as keeping these families engaged in
    treatment, are greatly needed.

32
Provision of Therapy Selected Recommendations
  • Develop Guidelines for Tailoring Evidence-Based
    Interventions
  • Identify salient factors are amenable to
    adaptation to provide a framework for continually
    assessing the interventions sensitivity in the
    face of changes in culture
  • Recognize Multiple Types of Research Evidence
  • Data collected through different research designs
    (i.e., clinical observation, qualitative
    research, systematic case-reviews, etc.) to
    include more diverse groups

33
Provision of Therapy Selected Recommendations
Contd
  • Consider views of mental health and service
    utilization practices
  • Use of alternative approaches to healing (e.g.,
    folks healing)
  • Involvement of extended family members in
    treatment
  • Utilize principles of community engagement to
    conduct research and disseminate treatments that
    are relevant and beneficial to the intended
    groups.
  • Therapists should be aware of their own biases
    and prejudiced beliefs toward the populations
    being served in treatment
  • Treatment providers should partner with case
    management services that facilitate access to
    culturally relevant services that address other
    challenges confronting Latino/Hispanic families

34
Communication and Linguistic Competence
Statement of the Issue
  • Communication and cultural barriers affect
    Latino/Hispanic families experiencing trauma in
    various ways. Many Latinos/Hispanics have limited
    or no English proficiency.
  • These barriers sometimes lead to poor service
    utilization, lack of treatment compliance,
    dropping out of treatment, misdiagnosis,
    misassessment, and experiences of discrimination
    that can lead to negative emotional and physical
    outcomes. For example, lack of communication
    competence, such as inadequate use of translators
    or incorrectly translated instruments, can lead
    to misdiagnosis.
  • Additionally, families with limited English
    proficiency may not know how to navigate the
    service systems and access trauma services. This
    may lead to higher dropout rates among families
    receiving trauma services, because they do not
    feel comfortable with clinicians with limited
    language proficiency and perceive them as lacking
    warmth or as cold or uncaring.
  • Therefore, it is important that individual
    therapists and organizations serving
    Latino/Hispanic children and families affected by
    trauma develop linguistic competence in their
    service provision.

35
Communication and Linguistic Competence Selected
Recommendations
  • Provider recommendations
  • Develop deep knowledge of their intended
    population and their communication needs
  • Translate all written materials using best
    practices available
  • Assess language needs individually and provide
    services that are linguistically attuned to those
    specific needs, matching the familys language
  • Organization recommendations
  • Develop strategies for hiring, recruiting and
    developing Latino clinicians who are bilingual
    and bicultural
  • Develop strategies for improving their
    personnels Spanish skills as well as other forms
    of communication
  • Utilize translated measures of the highest quality

36
Cultural Values Statement of the Issue
  • Latinos/Hispanics have a unique set of cultural
    values that shape their behaviors, thoughts,
    feelings, and overall worldview.
  • Not surprisingly, when trauma occurs in a
    Latino/Hispanic family, these values shape their
    reaction to the trauma, psychological
    consequences, coping responses, and meaning
    attributed to the trauma (Mennen, 1994).
  • It is pivotal for service providers working with
    Latino/Hispanic children affected by trauma and
    their families to become familiar with these
    values.
  • By developing familiarity with these values and
    incorporating these values into treatment,
    service providers can ultimately help these
    families process the traumatic event from their
    unique worldviews.

37
Cultural Values Selected Recommendations
  • Become knowledgeable about Latino-specific values
    and the moderating factors that may lead to value
    differences among family members
  • Conduct a Latino-value focused assessment and
    feedback session on these values
  • Assist families in understanding how their values
    shape their perceptions about the trauma, their
    psychological response, and approach to treatment
  • Assist families in reframing their perceptions of
    Latino values that may be hindering the child
    from processing and integrating his/her traumatic
    experience.

38
Resources
  • www.ChadwickCenter.org (Chadwick Center)
  • www.chadwickcenter.org/WALS.htm (Adaptation
    Guidelines)
  • www.nctsn.net (National Child Traumatic Stress
    Network)
  • www.musc.edu/tfcbt/ (TF-CBT on-line)
  • www.cachildwelfareclearinghouse.org (California
    Child Welfare Clearinghouse)
  • www.taptraining.net (TAP On-line training website
    under development)

39
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40
Contact Information
  • Clorinda Merino, M.Ed.
  • Project Coordinator
  • Safe Kids California Project
  • Chadwick Center for Children and Families
  • Rady Childrens Hospital, San Diego
  • 3020 Childrens Way, MC 5014
  • San Diego, CA 92123
  • cmerino_at_rchsd.org
  • Lisa Conradi, Psy.D.
  • NCTSN Project Manager
  • Chadwick Center for Children and Families
  • Rady Childrens Hospital, San Diego
  • 3020 Childrens Way, MC 5131
  • San Diego, CA 92123
  • lconradi_at_rchsd.org
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