System-Level Change in Cultural and Linguistic Competence (CLC): How Changes in CLC are Related to Service Experience Outcomes in Systems of Care

As US demographic trends shift toward more diversity, it becomes increasingly necessary to address differential needs of diverse groups of youth in mental health service systems. Cultural and linguistic competence (CLC) is essential to providing the most appropriate mental health services to youth and their families. The successful implementation of CLC often begins at the system level. Though various factors may affect change and system-level factors set the tone for broad acceptance of CLC within systems, there is limited empirical evidence linking culturally competent practices to outcomes. The purpose of the present study was to examine system-level CLC changes over time within systems of care and their associations with service experiences among youth and their families. Participants were 4,512 youth and their families enrolled in the national evaluation of the Children’s Mental Health Initiative (CMHI). Results suggest that implementation of CLC at the system level improves over time in funded systems of care. Further, variation exists in specific system-level components of CLC. In addition, the changes in CLC at the system level are related to family/caregiver participation in treatment. Implications for supporting positive changes in CLC among systems of care communities, and specific strategies for community psychologists, are discussed.     

Supporting the Need for an Integrated System of Care for Youth with Co-occurring Traumatic Stress and Substance Abuse Problems

Adolescents are at high risk for violence exposure and initiation of drug use. Co-occurring substance use and trauma exposure are associated with increased risk of mental health disorders, school underachievement, and involvement with multiple systems of care. Coordination and integration of systems of care are of utmost importance for these vulnerable youth. This study delineates the negative sequelae and increased service utilization patterns of adolescents with a history of trauma, substance abuse, and co-occurring trauma and substance abuse to support the need for integrated mental health and substance abuse services for youth. Data from two national sources, the National Child Traumatic Stress Network and Center for Substance Abuse Treatment demonstrate the increased clinical severity (measured by reports of emotional and behavioral problems), dysfunction, and service utilization patterns for youth with co-occurring trauma exposure and substance abuse. We conclude with recommendations for an integrated system of care that includes trauma-informed mental health treatment and substance abuse services aimed at reducing the morbidity and relapse probability of this high-risk group.     

Intervening in the Lives of Youth with Complex Behavioral Health Challenges and Their Families: The Role of the Wraparound Process

Wraparound is an individualized, team-based service planning and care coordination process intended to improve outcomes for youth with complex behavioral health challenges and their families. In recent years, several factors have led wraparound to become an increasingly visible component of service systems for youth, including its alignment with the youth and family movements, clear role within the systems of care and public health frameworks, and expansion of the research base. In this paper, we provide a review of the place of the wraparound process in behavioral health, including a discussion of the opportunities it presents to the field, needs for further development and research, and recommendations for federal actions that have the potential to improve the model’s positive contribution to child and family well-being.     

The Value of Lakota Traditional Healing for Youth Resiliency and Family Functioning

This article reports research findings on the impact of Oglala Lakota Sioux traditional healing on family functioning and youth resiliency where trauma, abuse, or violence are often present. Caregivers of Lakota youth struggling with serious emotional and behavioral problems participated in the study. The study included both quantitative and qualitative samples: 27 families for the quantitative sample and 8 families for the qualitative sample. Results from caregivers revealed that traditional healing and cultural practices, as well as the promotion of cultural identity, had statistically significant positive effects on the perceived familial and individual functioning of Lakota youth and their families. Effect sizes indicate that the results have strong practical significance.     

The Relation of Exposure to Traumatic Events and Longitudinal Mental Health Outcomes for Children Enrolled in Systems of Care: Results from a National System of Care Evaluation

This study examined the relation between children's history of exposure to potentially traumatic events (PTEs) and clinical and functional mental health trajectories over a 18‐month period among a national sample of youth referred for services in children's behavioral health systems of care (SOCs). Using data from the national evaluation of the Comprehensive Community Mental Health Services program for communities funded from 1997 to 2000, the study sample included 9556 children and their families. Latent growth modeling was used to assess the effect of history of exposure to PTEs on trajectories in a number of behavioral health outcomes during the 3‐year period following referral to services, controlling for child demographic characteristics (gender, race, and age). Results revealed that, on average, children in SOCs exhibited significant improvements over time on all four outcome measures. Children with a history of exposure to PTEs had higher rates of internalizing and externalizing problem behaviors and functional impairments and fewer behavioral and emotional strengths at baseline, but experienced improvements in these outcomes at the same rates as children without exposure to a traumatic event. Finally, child race, gender, and age also were associated with differences in behavioral health trajectories among service recipients. Implications for SOCs, including approaches to make them more trauma‐informed, are discussed.     

When Treatment as Usual Gives You Lemons,Count on EVBPs: Economic Arguments for Training Child Clinicians in Evidence-Based Practices

This article is a commentary advocating for dissemination and implementation workers to incentivize the adoption of evidence-based practices (EVBPs) with youth. Treatment-as-usual in community settings yields weak effectiveness results. EVBPs for youth exist but are not widely adopted. Consequently, “lemons” or poor treatments are added to the behavioral health care marketplace. The economic concept of lemon market theory is explained and its relevance to the behavioral health care marketplace is illustrated. Several recommendations based both on economic and learning theory are offered. The article argues for the increased use of incentives as behavior modifiers for clinicians’ practices. More specifically, proper branding and fidelity, quality improvement measures, and pay for performance initiatives are discussed.     

Striving for a culturally responsive process in training health professionals on Asian American and Pacific Islander youth violence prevention

The quality of youth violence prevention practice is dependent on the quality of education and training of professionals who will care for disadvantaged and/or underserved youth. The authors propose that culturally responsive youth violence prevention curricula, focused on Asian Americans and Pacific Islanders, should: 1) target institutions that train health professionals likely to serve Asian Americans and Pacific Islanders; 2) promote the professional development of Asian American and Pacific Islander students and enhance all students' comfort in addressing behavioral, social, and cultural concerns; 3) cover specific issues relevant to Asian Americans and Pacific Islanders, including the role of acculturative stress, socioeconomic hardship, and other risk factors that may account for mental health disparities; and 4) continuously engage researchers, educators, and community stakeholders in cooperatively and creatively applying new knowledge to clinical challenges. The authors summarize resources for youth violence prevention education that have been used for training healthcare professionals in a multicultural context.     

American Indian Youth: Who Southwestern Urban and Reservation Youth Turn to for Help with Mental Health or Addictions

We illustrate the addictions and mental health service use of American Indian adolescents. Interviews concerning mental health need and service configurations with 401 Southwestern American Indian (AI) youth used questions from the Diagnostic Interview Schedule (DIS) and the Service Assessment for Children and Adolescents (SACA). Seventy-nine percent had mental health or addiction problems, with half meeting criteria for at least one diagnosis. One in 4 youth met criteria for drug dependence'abuse or conduct disorder, 1 in 5 for depression, and 1 in 8 for alcohol dependence'abuse. Most youth were helped by a combination of providers. Youth meeting more diagnostic criteria were increasingly likely to use service configurations with adults, nonspecialist professionals, and specialists, respectively. Regardless of disorder, youth were least likely to use configurations with traditional healers or specialists and there was little difference in rates of use between the two. The lack of services from specialist providers was potentially offset by use of an extensive range of informal adults, nonspecialist professionals, and peers. Since informal helpers, peers, and nonspecialist providers, but not specialists, are providing the bulk of services they must be given support and skills so they can function effectively.     

People Awakening: Collaborative Research to Develop Cultural Strategies for Prevention in Community Intervention

The consequences of alcohol use disorder (AUD) and suicide create immense health disparities among Alaska Native people. The People Awakening project is a long-term collaboration between Alaska Native (AN) communities and university researchers seeking to foster health equity through development of positive solutions to these disparities. These efforts initiated a research relationship that identified individual, family, and community protective factors from AUD and suicide. AN co-researchers next expressed interest in translating these findings into intervention. This led to development of a strengths-based community intervention that is the focus of the special issue. The intervention builds these protective factors to prevent AUD and suicide risk within AN youth, and their families and communities. This review provides a critical examination of existing literature and a brief history of work leading to the intervention research. These work efforts portray a shared commitment of university researchers and community members to function as co-researchers, and to conduct research in accord with local Yup’ik cultural values. This imperative allowed the team to navigate several tensions we locate in a convergence of historical and contemporary ecological contextual factors inherent in AN tribal communities with countervailing constraints imposed by Western science.     

Adolescent health. Challenges for behavioral scientists

Clearly, the role of behavioral scientists in adolescent health is not limited to service delivery. They also have a role to play via their contributions to basic knowledge of adolescent health and development, their involvement with the design and evaluation of health systems, their efforts to design and evaluate interventions to reduce adolescent morbidity and mortality, and their contributions to adolescent health policy. The once popular view of adolescence as a period of inevitable storm and stress has been replaced by one that emphasizes the potential of this developmental stage for constructive adaptation and maturation. Behavioral scientists have an important role to play in assuring that the potential of this life stage is reached for future generations of youth.     

Urban American Indian Youth Spirituality and Religion: A Latent Class Analysis

This article explores the interconnected spiritual, religious, and cultural worlds of the majority of American Indian (AI) youth who live in urban areas: their patterns of involvement in religion and Native spirituality and associated well‐being. Latent class analysis of data from 205 AI middle school students identified five distinctive classes using survey measures of religious affiliation, attendance at services, adherence to Christian and traditional spiritual beliefs, Native spirituality, and Native cultural practices. Two classes were Christian groups: one attending Christian churches and following Christian beliefs but uninvolved with Native beliefs, spirituality, or cultural practices; and a nominal Christian group affiliated with but not attending church and unattached to belief systems. Two groups followed Native beliefs and spiritual practices, one affiliated with the Native American Church and another unaffiliated with any church. The fifth, nonreligious group, had no religious affiliation, followed neither Christian nor traditional beliefs, and was uninvolved in Native spirituality and cultural practices. The two groups embracing AI spirituality reported better academic performance, more reservation contact, higher AI enculturation, and stronger bicultural orientations.     

“I’m Not Sure I Trust the System Yet”: Lesbian Service Member Experiences With Mental Health Care

The purpose of this research was to understand lesbian service member experiences with mental health care. Individual and organizational factors were explored, including the influence of military policy (e.g., “Don’t Ask, Don’t Tell”) on service member utilization of mental health services. Thirty-seven participants responded to a survey containing 16 open-ended items regarding the impact of “Don’t Ask, Don’t Tell” on one’s professional life, relational life, identity, and willingness to access mental health services. Data were analyzed through an open- and axial-coding and constant comparative method. The findings indicated a lesbian service woman’s likelihood of accessing mental health services was impacted by confidentiality concerns, fear of repercussions, and a sense that military culture lags behind policy changes. Recommendations for therapists included renewed focus on safety through affirmative practices, need for competency in military and lesbian/gay culture, and sensitivity to the effects of systemic oppression on self-esteem. Implications and future research are discussed.     

Spirituality and mental health status among Northern Plain tribes

Spirituality measures often show positive associations with preferred mental health outcomes in the general population; however, research among American Indians (AIs) is limited. We examined the relationships of mental health status and two measures of spirituality – the Midlife Development Inventory (MIDI) and a tribal cultural spirituality measure – in Northern Plains AIs, aged 15–54 (n?=?1636). While the MIDI was unassociated with mental health status, the tribal cultural spirituality measure showed a significant relationship with better mental health status. Mental health conditions disproportionately affect AIs. Understanding protective factors such as cultural spirituality that can mitigate mental health disorders is critical to reducing these health disparities.     

“Chaotic soup of politics:” a Native American Indian mental health perspective

Through a grounded theory process, tribal politics emerged as a core theme from interviews with mental health providers (MHPs) and Native American Indian people experiencing persistent mental illness (PMI). Interviews were conducted over a four-year period with 13 Indian MHPs and administrators, and 18 persons experiencing PMI. Symbolic Interactionism was the informing framework. Findings indicate that reservation life promotes a high immersion in Eurocentric politics, which negatively affects the person with PMI in their maintenance of a healthy spirit balance. To be effective, MHPs need immersion in; the oneness of culture, spirituality, and politics of the community; knowledge of the tribal history; and communication with elders/spiritual leaders. This personal growth could facilitate provision of culturally responsive care needed for a client's navigation of intergovernmental regulations. MHPs should work for adequate funding policies of human service centers while supporting the establishment of indigenous governing practices through tribal sovereignty.     

Intensive Home Based Services Within a Comprehensive System of Care for Youth

Within a comprehensive mental health service array for youth, Intensive Home Based Services (IHBS) are designed to meet the needs of youth with significant emotional and behavioral problems in their home communities, avoiding the need for out-of-home services, particularly residential care. We examined youth receiving IHBS as their first service in the state of Hawaii system of care (N = 163) to determine how successful IHBS were in preventing the need for more restrictive services within 12 months of intake. Subsequently, we investigated characteristics that might be predictive of a youth’s need for service intensification within 12 months. Logistic regression analyses found that greater age, level of service need, and functional impairment at intake predicted use of more restrictive services within 12 months of intake, whereas gender, ethnicity, diagnosis, service intensity, and clinician credentials did not. Overall, our findings suggested that IHBS were reasonably successful in preventing residential placements, and provided some basis for determining characteristics of youth likely to require more restrictive placements within a one year period.     

The impact of stigma on behavioral health care utilization among active duty service members

This study assessed the relationship between the stigma of seeking psychological help and use of outpatient behavioral health services over a 2-year period among active duty military service members initially referred for neuropsychological evaluation secondary to their histories of mild traumatic brain injury. Although research has examined how stigma predicts proxies for help-seeking (i.e., attitudes towards/intentions to use services), very little research has looked at actual behavior, and studies that do have largely focused on previous use. In this study, we examined the relationship between participants’ stigma and subsequent behavioral health use. Our results indicated that whereas greater self-stigma (i.e., negative self-judgments for seeking psychological help) was associated with attending fewer behavioral health care sessions, public stigma (i.e., perceptions of public attitudes towards people who seek psychological help) was not associated with service use. These findings support the need for addressing the self-stigma associated with seeking behavioral health care.     

Clinician Perspectives of Diagnosis and Perceived Client Change in “Real World” Psychotherapy for Youth Emotional and Behavioral Disorders

We investigated the extent to which clinician-assigned diagnoses of emotional and behavioral disorders and clinicians’ perceptions of client change are consistent with structured measures of youth clinical functioning and parent/family characteristics within the context of usual care or “real world” psychotherapy. A total of 54 therapists from two publicly-funded youth outpatient mental health clinics and 128 youths and parents from the therapists’ combined caseloads were included in the study. Clinician-assigned diagnosis and youth and family demographics were collected at the initial visit, clinician-reported perceived client change was collected at 6-month follow-up, and structured measures of youth clinical functioning and parent/family characteristics were collected at both time points. Results indicate some overlap between clinician-assigned diagnosis, clinician-reported perceived client change, and structured measures of youth clinical functioning and parent/family characteristics after controlling for demographic factors. Results are discussed in terms of implications for the implementation of evidence-based practices in real world community settings.     

The Role of Religion on the Health Practices of Mexican Americans

Twenty million Mexican Americans live in the U.S. (U.S. Census 2000 Summary File, 2000). It is vital that health care clinicians become familiar with and acknowledge the role of religion or religiosity on the health practices of Mexican Americans so that these needs may be addressed through holistic care. This paper reviews the origin and role that religion plays in the health practices of Mexican Americans. The potential benefits of addressing these client’s religious needs are examined and suggestions are offered on how health care clinicians may address these needs in a culturally sensitive manner.Josefina Lujan, MSN, RN is a first generation Mexican American who has been practicing nursing for 25 years in the Texas-Mexico border community of El Paso, Texas.Howard Campbell is an associate professor of anthropology at the University of Texas at El Paso. e-mails: jlujan1@utep.edu; hcampbel@utep.edu