AACAP Helps Psychiatrists Address Patients’ Cultural Factors

Psychiatrists are treating an ever-increasing racially and ethnically diverse patient population and have been urged to hone their cultural awareness. For child and adolescent psychiatrists with patients under age 8, no population group constitutes a majority.

To enable child and adolescent psychiatrists to better evaluate and treat patients from a variety of racial and ethnic backgrounds, the American Academy of Child and Adolescent Psychiatry (AACAP) in June released its “Practice Parameter for Cultural Competence in Child and Adolescent Psychiatric Practice.” Members of the AACAP Committee on Diversity and Culture wrote the parameter, and members of the AACAP Committee on Quality Issues cowrote, edited, and reviewed it.

The information in the parameter is based upon an extensive literature review and committee members’ expertise.

Courtesy of Andres Pumariega, M.D.

“There is a great deal of evidence showing that culture makes a huge difference in diagnosis, treatment outcome, help-seeking behaviors, acceptability of treatment, and even the way a medication is metabolized,” Andres Pumariega, M.D., told Psychiatric News. Pumariega is first author of the parameter as co-chair of the AACAP Committee on Diversity and Culture and is a professor and chair of the Department of Psychiatry at Cooper Medical School of Rowan University and Cooper Health System in Camden, N.J.

The parameter is divided into 13 principles that cover a wide range of mental health issues relating to culturally diverse children, adolescents, and their families. It initially describes possible barriers to treatment for these young people, including stigma, financial problems, and lack of transportation. It also points out the possibility that some minority families have a higher threshold for disruptive behaviors and thus might not seek professional intervention for their children until the situation becomes unmanageable.

Language Issues Can Be Crucial

Two of the principles focus on language. One urges clinicians to evaluate patients in the language in which the child and family are proficient. To accomplish this, an interpreter with both proper training in the skill of interpretation and the content area being discussed should be used. The parameter warns against the use of language brokering, or “the common use of having children act as interpreters between parents and medical and school authorities.” Where no live translation services are available, telephonic translation services may be helpful, although nonverbal cues are lost.

The practice parameter also points out that 20 percent of U.S. children grow up speaking two languages. “There is evidence that maintaining the first (home) language is important in accessing family and community protective factors and other benefits,” according to the parameter. However, for children experiencing language or cognitive delays, some clinicians have endorsed a “poorly substantiated practice of recommending to parents that they discontinue speaking the home language to the child.”

Other aspects of the parameter deal with the stresses that immigration can place on the child and family, including persecution and torture in the country of origin, disruption and separation of families, traumatic journeys, and detention in refugee camps. It also addresses postmigration stressors such as acculturation and exposure to crime and violence. “Second-generation children of immigrants are…at increased risk for mental health problems, including anxiety, depression, substance abuse, and PTSD,” the parameter notes.

It also urges clinicians to carefully monitor their attitudes and beliefs about people of other cultures. “I think this is a matter of applying countertransference to cultural values,” Pumariega said. He also noted that some clinicians may find cultural-sensitivity sessions helpful in learning about the perspectives of people from different ethnic backgrounds.

DSM Formulation Complemented

Francis Lu, M.D., a member of APA’s Council on Minority Health and Health Disparities, says the parameter “beautifully highlights the five areas of assessment in the DSM-IV Outline for Cultural Formulation, which has been updated for DSM-5.” Lu is a professor of psychiatry emeritus at the University of California, Davis.

Lu pointed out that the parameter addresses the clinical utility of assessing cultural stressors and strengths for immigrants and refugees, family conflicts related to acculturation differences among family members, and indigenous/traditional cultural strengths with which clinicians may not be familiar. He also noted that the parameter calls upon clinicians to apply their knowledge of cultural differences to the manifestation of mental illness symptoms, the ways in which patients express their distress, the diagnostic process, and the treatment-planning process. “This is how the ‘rubber meets the road’ to improve the quality of care for populations that are often underserved,” Lu noted.

According to Sandra Walker, M.D., chair of APA’s Council on Minority Health and Health Disparities, “With diversity among our child and adolescent populations becoming the rule, not an exception, we as clinicians must become more attuned to the needs of youth whose cultural experience is different from our own,” she told Psychiatric News. The principles in the parameter also “underlie the cultural formulation interview now available in DSM-5 to bear on our work with children and teens,” noted Walker, who is a courtesy clinical associate professor of psychiatry and behavioral sciences at the University of Washington.

Both Pumariega and Toi Harris, M.D., a member of AACAP’s Committee on Diversity and Culture and a coauthor of the parameter, believe that it can serve as an educational tool for all psychiatrists. Harris said that the parameter “can serve as a template for mental health and medical educators to utilize during the training of medical students, residents, and fellows, and the 13 guiding principles can serve as topics to address within a course or seminar addressing cultural competence education.” She is an associate professor of psychiatry and pediatrics and assistant dean of student affairs and diversity at Baylor College of Medicine.

“We are hoping this practice parameter will promote continuing education and further research at the intersection of culture and mental health,” Pumariega emphasized. ■