Considering Culture in Child and Adolescent Care

Once upon a time our society began teaching children the story of Christopher Columbus, which inhibited children from developing critical multicultural thinking and reinforced racist ideology. A big and powerful “white” country is invading the country of poor Indians of color. You know the rest of the story.

Nowhere can issues of cultural diversity and change be addressed as clearly in the curriculum as they can be in early education, for there is a long-held belief in our field that concepts of health and disease are intrinsic to every culture and ethnicity and are, therefore variable. Multicultural behavioral health is concerned with a myriad factors contributing to disorders, etiology of dysfunction, and a variety of ways in which human populations respond behaviorally to psychological distress (clinical manifestations) and the person’s experience. It is not only the assumptions concerning education, health and illness that are culturally based but the very language we use and the questions we raise that are culturally driven as well. The United Sates as a culturally diverse society provides a fertile background for teaching cultural diversity, environmental and ethical issues relating to the behavioral health of children and adolescent.

Historically, ethnic diversity in the U.S. derived from two sources the diverse indigenous populations of Native Americans, and the diverse populations of immigrants, both voluntary and involuntary. Though there has been a significant amount of gene flow between these diverse populations, patterns of socially constructed isolation and inequality of access to both physical health and behavioral health resources have led to dramatic differences in illness patterns and rates of morbidity and mortality at various points in time. Far too often explanations of these epidemiological patterns have been laid solely at the feet of “cultural behaviors and belief”. Medical science has contributed to this misconception; more recent analyses have focused on inequalities of power, and the “medicalization” of difference brings new insights to the relationship between the social environment and behavioral health.

For example, the very establishment and growth of the United States was accompanied by the dislocation and destruction of a myriad of indigenous peoples who had successfully managed local ecosystems for long-term sustained use. In addition, these societies were, in general, characterized by internal social equality which allowed for satisfaction of human needs without elevating production and consumption beyond local subsistence demands. This pattern is in marked contrast to that of industrialized capitalist and post-revolutionary communist states alike. J. Bodley, (1990) noted, the notion of “progress has ushered in an explosion of population growth and consumption of resources unparalleled in scope and catastrophic in the nature of the transformation that it has initiated.” Any critical examination of environmental issues related to health in the United States must focus on investigations of “race” ethnicity, gender, and the class that have accompanied this transformation of disparities.

Culture, “race,” gender, ethnicity, and socio-economic status of children plays a major role in shaping the behavioral health care provided to children by health institutions. “Racial,” ethnic and cultural differences influence the expression and identification of the need for services. Studies have shown ethnic and “racial” differences in youth’s self-report of problem behaviors, caregivers’ value judgments of what is normative behavior, and care giver expectations of the child. Ethnic and “racial” bias in who gets identified, referred and treated within certain institutions has also been documented. For example, African origin youth are more frequently referred to conduct problems for correction rather than psychological services, even with lower or equal measures of aggressive behavior. Quality of care is also impacted. For example, ADHD is less often treated by medications in “minority’ groups than in “white” populations. There is also a high probability of misdiagnosis among “minority” individuals, affecting subsequent care.

Furthermore, there are challenges in identifying the mechanism by which “race” and culture accounts for disparities in behavioral and emotional problems and service delivery. Understanding this mechanism has important implications for how to intervene correctly. Factors that mediate such challenges may be related to lack of early detection by providers and parents; untrained and culturally biased providers; lack of parent and provider knowledge of efficacious treatment. For example, “Latino” youth have the highest rate of suicide, yet they are less likely to be identified by their caregivers as having problems. Disparities in service may be due to different barriers such as insurance status and setting where behavioral health services are delivered. “Minority” children tend to receive behavioral health services through the juvenile justice and welfare systems more often than through schools or special settings.

Unfortunately, efforts to address “racial” and ethnic disparities in behavioral health delivery are constrained by profound socio-environmental, institutional and market forces. Currently young people in the U.S. are increasingly ethnically diverse. Data indicates that children and adolescents of “color” make up as much as 40% of the U.S. population. It is estimated that the “Latino” population will become the largest ethnic group in American society. Asian and Pacific Islander make-up the second fastest-growing “minority;” of that group 50% are new immigrants, and about one third are younger than age 17. The African origin population is expected to increase 12.5% with 50% of those individuals being under age 17. The Native American Indian population is expected to increase to 6.0%, 25% of whom will be adolescent. Concurrently, the population of Caucasian children in the U.S. is expected to decrease by about 3.0% (U.S.Census Bureau, 2007). Alarmingly, 7 million children, or 10% of the population under age 18, have a parent under some form of correctional supervision, (Bureau of Justice, 2006).

Failure to adapt children and adolescent services to various socio- cultural perspectives can result in the underutilization of services and consequently can result in unmet needs. The increasing magnitude of poverty, substance use/abuse, violence, illiteracy and teen pregnancy have profound effects on the unmet service needs of diverse populations. Our efforts must focus not only on equalizing access to services, but also on equalizing outcomes of care. Moreover, we must move beyond policy interventions to more socio-education approaches, where government agencies are not agents of control but agents of support and change. Early identification and education about psychosocial disparities and culturally flexible definitions of behavioral problems can assist in the prevention and provision of services to multicultural children and adolescents.

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