When programs strive to be culturally competent, the result should be that families are “culturally comfortable.” Most parents and youth can tell you whether it is easy and comfortable for them to be connected to and involved with a program. Feeling culturally comfortable helps families decide how they view a program, a worker or a service.
I first encountered the term “culturally comfortable” in the guide, Working with Families of Children in the Juvenile Justice and Corrections Systems. As Trina Osher and Barbara Huff note, some families may require a boost to become involved with their child’s services or program. They list some key strategies to provide that boost and providing culturally comfortable settings is a priority.
The term “culturally comfortable” has been cropping up in health and education settings for a number of years now. Many urban health centers have changed how they practice, finding new ways to share health information and deliver care. Some ask patients how they think a condition should be treated before offering their own recommendations. One pediatric practice in Virginia explored creating a “culturally comfortble” medical home. Some preschool educators have also been strong proponents of ensuring that their classrooms are culturally comfortable. Beverly Gulley and Nillofur Zobairi write that educators need to “know and understand the family’s cultural orientation to make a child feel comfortable and secure, and provide a sense of continuity.”
While cultural competence is a core value for both wraparound and creating a systems of care in children’s mental health, the notion of “culturally comfortable” settings or practice has yet to show up. I think it’s about time. Cultural competence is a rich, complex yet formal standard and most parents and youth would be hard pressed to say how close a setting or practice is to getting there. Yet they would be able to judge whether it was culturally comfortable. Feeling comfortable or uncomfortable is something we are all familiar with. Culturally comfortable settings, dialogues and practice make families feel welcome and respected.
Increasing cultural competence in the delivery of mental health services for children can help reduce disparities and increase access. But these results are frequently unknown to families, especially if the changes are gradual. Changing a setting, practice or dialogue so that it becomes more “culturally comfortable” is something that families can notice and determine for themselves. Determining whether that change is happening can empower parents and youth. Early in the family movement, parents often judged whether materials, programs or approaches were family friendly and later family dirven. So, too, can parents and youth figure out if materials or programs today are culturally comfortable.
Building an approach that is “culturally comfortable” starts with communication and awareness. Find out what the family values, who its members are, what the concerns and goals for its children may be. Ask families what matters to them. Find out what is private in a family and what is easily shared. Culture influences parenting and family behaviors, including meals, sleep, how to dress, interaction with both adults and other children, health care, how to show affection and respect, ways of celebrating and what occasions to celebrate. Many different family configurations are out there. Celebrate moms, dads, grandparents, extended family members, siblings, and others important to children. Model respect and show that customs, languages, cultures, and physical attributes different from your own are important and to be honored. Diversity in our society should be valued and enjoyed, not considered a threat to the values or lifestyle of any group.
Catherine Stakeman, Maine NASW, said that “becoming culturally comfortable between all cultures is a journey, and there is always room for improvement.” To make it happen, it must be everyone’s responsibility.
I have been exceptionally good this year. Well, at least I’ve tried really hard to be good. But there are all sorts of things that can get in the way.
I’ve been doing extra chores this year. It’s hard to pick up after children that hide things, especially cookie dough behind the cabinets, snacks in drawers, and even the papers that get ripped up into a million little pieces because it is an “activity” that keeps one of my kids busy. It can take a huge amount of planning to get the chores done and also manage to pick up and move pictures to the holes in the walls so that the visitors do not feel they have entered a “unsafe ” place.
I am not even talking about the singing that I have to do to get my daughter to eat, or the dancing I must do to get her to drink. It is difficult being the mom and the entertainer. Combining discipline and building positive self esteem is hard. NOT like the Italian home I grew up in.. you knew if the wooden spoon was raised you ran!
I have also tried to go grocery shopping at 11pm so that my children are sleeping all nestled in their beds and limit the number of customers who point at me and say “That”s the mom with the unruly child.” It also helps with the child who feels he needs to eat certain things to keep the voices in his head away.. if you drink lots of water you will not hear the scratching on the window that is not there.
I am trying to be nice to everyone but Santa, have you ever called Mobile Crisis? They want you to schedule a time for the crisis! When you call, they seem to always say it is shift change and they won’t have a clinician in for four hours. How do you pause a crisis? I call, at first to explain, then I’m more demanding but still patient, and then okay, I talk about the laws and then I’m called the parent OUT OF CONTROL.
Santa, I’ve spent a lot of time teaching too. Everywhere I go it seems I have teaching to do — grocery stores, banks, even people in cars looking as you are waiting for the stop light. Seems like everyone has to LOOK at our kids and judge us. So I am trying Santa.. but it gets hard. The new item in the state is Wraparound. What they don’t tell you is…well, can you imagine not believing in strength based families? Why is it such a hard concept? And you know my tough child–the one that hears voices–who doesn’t know what to do and sometimes wonders why he should continue to try? This Wraparound thing would never work for him because he is too unique–the system calls him too complicated.
Finally.. I really want to go back to DMH and get a caseworker that believes in families, believes in clinical help. They call back, they support, and guess what .. they do not want to file 51As. I am trying to believe that the professionals in Wraparound will get it.. but how many times do you need to change teams in order to succeed?
So I hope all this counts. My list this year is a list of the things I think would help me with the system. It’s a little like a top 10 countdown (I would love to be Jay Leno, or Letterman). Will people get my sense of humor? It is different then most… I guess not really if you have a child like mine.
The items on my list are in the order of importance, so if there are too many things for you to carry, please delete as few of the items as possible, starting from the bottom of my list.
Santa, I will leave you organic oatmeal cookies and soy milk (in case you are lactose intolerant) and carrots for your reindeer (organically grown of course).
Thank you in advance. I know you receive a lot of letters so you don’t need to reply unless there is a problem with my list or you need services for another child. I have taught myself to be resourceful so please let me know if I can help someone else get it right!
10. Mobile crisis to move in my home
9. Clinicians who will talk to all parts of the team
8. Schools that do not depend on the parent to play expert, and then blame them if it doesn’t work
7. A secretary
6. A full time nurse – those somatic symptoms creep up on us
5. News station to teach the public about children’s mental health
4. Safety protection.. not what you are thinking… i want bubble wrap so when the heat is hot.. i am protected!!!
3. Another set of eyes.. reality tv please. The money would pay for the lawyers.
2. I always wanted more children, so for this one could each kid in DCF or any other system get a someone to call mom, dad, grandma or grandpa?
1. Ok.. I have decided.. nothing can be cut off my list…I need it all to make things work
When my son was seven, he had his first psychiatric hospitalization. He had become incredibly afraid of going to school and was often unable to get there. He had nightmares almost every night and was frightened by television shows he used to enjoy. He started talking about suicide and began to hurt himself. In short, his world was filled with pain and fear. It finally led to a hospital admission.
I took his four year old brother to see him. He watched with wide eyes as the many locks on the psychiatric unit were opened to let us in and then the doors were locked behind us. He looked at his older brother and asked, “Don’t you just feel like a monkey in a cage?” “No,” his older brother vehemently said, “It’s safe in here and nothing can hurt me.” So from the beginning it was clear that they were going to have two very different views of the treatment, the behaviors and the impact of mental health needs.
Mental health issues impact not just one child, but the entire family. When parents have the chance, they can share with each other their sadness, anxiety, anger and frustration. Even though they are also profoundly impacted, siblings have few places to get information, safely vent or even get a break. When talking about my two sons, I often say that one has a diagnosis and the other experiences “sibling spillover.” When I use this term to a group of parents, they nod their heads with recognition. Sibling spillover happens in a lot of homes.
The impact on siblings whose brother or sister has significant mental health needs is just beginning to be studied. Until now, most research has been focused on siblings whose brother or sister has developmental delays, autism or chronic illness and even that is uncommon. Emily Rubin, Director of Sibling Support at the Shriver Center, says that “the most effective intervention is for parents or guardians to talk openly with siblings at an early age, acknowledging their complicated family lives in age-appropriate language.” She wrote an excellent brochure for parents, one of few available resources.
Most siblings whose brother or sister has special needs notice that much of the attention, resources, time and energy seems to be unfairly divided. And siblings can feel angry, resigned and ignored. But when your brother or sister also has behaviors that can be aggressive, bizarre, frightening or embarrassing, there’s even more to cope with.
Siblings have a variety of coping mechanisms. Some become the “good child,’ others withdraw and some may even mimick the behavior that seems to get all the attention. When they grow up, many go into “helping” professions (teacher, therapist, etc.) while others move across the country. At least for a while.
As for my two sons, I was advised that things would get better as they got older. My younger son went from saying that his brother was “a good boy who did bad things” to saying that he was a “terrible brother.” I noticed that my older son often got along better with adults than peers and waited for the day they would both be young adults. Gradually, they rediscovered the common ground that comes out of sharing experiences as a family. Siblings in the same family often see things differently and that’s okay. Maybe that’s the way it should be.
The new DSM 5, the bible for psychiatric disorders, intends to do away with a bipolar diagnosis for many children and teens. A new diagnostic category, temper dysregulation disorder (TDD) is being proposed and would include symptoms of bipolar disorder. The new diagnosis of TDD (does this really denote a serious medical condition?) will surprise and dismay many parents. Families usually struggle for years with their child’s unpredictable behavior, intense moods and volcanic temper tantrums while strangers, friends and family assume that what is wrong is inadequate parenting. A bipolar diagnosis has helped many parents get treatment, school services and a recognition that what they are dealing with at home is serious stuff indeed.
The DSM is many things to many people. Mental health clinicians rely on it to help form an accurate diagnosis. Insurers use it to authorize payment for medically necessary treatment. Schools often cite diagnoses in the student’s education plan. Even juvenile courts use it to better understand the behaviors that might bring a youth into court.
The DSM 5 Child and Adolescent Disorders Workgroup has listed several reasons for the recommended change. The rise in prescribing psychotropic medications for children is one. The group also cites a study that “found a 40-fold increase between 1994 and 2003 in the number of outpatient pediatric psychiatry visits associated with the diagnosis of BD [bipolar disorder].” Yet, a 2007 study found that youth released from the hospital with a primary diagnosis of bipolar amounted to less than one in a thousand.
But in 1994, practically no children were diagnosed with bipolar disorder, so any increase from “almost nothing” would be startling. In the early 90s, I was running support groups where parents would share stories with each other about their child’s moods (from rage to extreme silliness to wanting to die), the nightmares that came almost every night, the rigid food preferences and risky behaviors. Most parents worked, had little support and felt overwhelmed by the impact on their family. Parents were told their children had ADHD, anti-social personalities, were oppositional or had conduct disorder. Somehow these diagnoses didn’t capture the gravity or complexity of the situation.
The DSM is not a coding system set up for the convenience of the insurance industry or to create a shorthand for schools. Yet, a child must often be labeled “something” in order to get services. We all give lip service to measuring the “functioning” of a child but that still doesn’t open doors or get services paid for. The reality is that parents often have to fight for services. We may decry the need for labels and powerful diagnoses, but at this point in time it’s what we have. Those diagnoses have to increase access for children as well as describe their symptoms.
Most of the children and youth who now have a bipolar disorder diagnosis require medication, therapy, special education strategies and a loving, dedicated parent who is willing to do battle to obtain the needed treatments and services in order to improve things. It’s a diagnosis that does not imply that “bad” parenting is the cause, which allows parents to be partners in creating and carrying out a treatment plan, just as they would if this were any other medical illness. It also does not imply the child is to blame, which is often equally important.
Any new diagnosis proposed by the DSM 5 needs to send a clear signal to insurers, schools and the general public that bipolar in children is very real and very serious. Parents already know this. There is still time for comments at www.dsm5.org until April 20, 2010.
Yes, there’s been a gap between the last post and this one. I got a house ready to be sold, sold it and am getting ready to move. It certainly devoured a lot of my time. But I have been thinking about children’s mental health a great deal and the posts will keep on coming!
Parents often call their experiences with the children’s mental health system “war stories.” Others talk about being “in the trenches” or describe how they “battled” the school system or “fought” to get services. Other parents, listening to these accounts, nod their heads in agreement. Many feel as if they really are at war or at least engaged in a prolonged battle.
We all organize our social experiences using “frames.” According to sociologists, a frame is a model used to interpret events or experiences. We then depend on that model to understand and respond to new events. Families are thrust into the world of children’s mental health feeling unprepared and overwhelmed. We try to understand not only the “system” we must navigate but also interpret our experiences in a way that makes sense and helps us strategize. A great many families find that a framework using combat terms resonates with them and matches their experiences.
In the theory of framing, there are 3 tasks which help mobilize us. First we diagnose (we identify the problem and figure out who or what is to blame). The second step is to predict or figure out what we will do (we suggest solutions and strategies). The last step is motivational framing (where we have a call to action).
When my child was seven, I had an experience that that mobilized me in just this way. My son was terrified to leave the house (which made going to school nearly impossible and most days were filled with either rages or suicide threats). My school system agreed he needed to be evaluated and the school psychologist ran a battery of tests. I was sure that she would see that he was in terrible emotional shape and would help figure out what he needed. We went over the test results and she noted that he had a “very high IQ.” She smiled at me and I smiled at her, sharing that he had this wonderful strength. She then looked me straight in they eye and remarked, “His father must be very smart, I would guess.” While my jaw dropped, she went on to say that his intelligence would overcome any emotional challenges and she was not recommending any services.
Like many parents, my approach and understanding of the system changed radically in the next few days. I had expected to create an alliance with the school psychologist and instead found we viewed things very differently. I needed to figure out strategies to get my son the supports he needed. Most of all, I shifted from expecting consensus to gearing up for advocacy. And that was successful for me.
Framing is a powerful tool for each one of us, whether we use it consciously or not. When we frame our experiences, it can affect the outcome. This is one of the reasons families use the concepts of gearing up for battle or defending their children. It empowers us, creates focus and we all feel as if we are comrades in arms.
With the new Children’s Behavioral Health Initiative, Massachusetts is changing how we deliver services to children with mental health needs and their families. The new approach is based on collaboration, coordination and the creation of a team for the child and family. Words of war won’t fit as well in this model. However, any new “frame” must reflect the realities that families experience and seem relevant to our values. If not, it simply won’t be adopted.
Can we transform our framing? Only time will tell.
By the time parents find us at the Boston or Worcester PAL office, their child usually has a lengthy list of mental health diagnoses. Part of what might prompt that first call is the sense of panic or desperation a parent feels just reading and trying to absorb what this list means. The more diagnoses, they reason, the worse off my child must be. When we get to the part of the call where the list is recited, the diagnoses often are overlapping, repetitive or seem to have evolved something like this: first there was ADD, then depression was added and later someone diagnosed (and added) bipolar disorder. Anxiety or a sleep disorder was thrown into the mix along the way. On top of all that, no diagnoses whatsoever have been eliminated.
This experience is what I call the “morphing” diagnosis. Remember those 90s videos or TV ads where one face was blended into the next and the next? Wikipedia calls morphing “a special effect that changes one image into another through a seamless transition.” Thus, the ADD child is changed into the depressed child and then into the bipolar child while the parent tries to understand what is taking place.
This is a very common experience. And it happens to a lot of families. According to the U.S. Surgeon General, mental health disorders occur in about 20% of children in any given year and about 5 million children and teens have a serious or significant mental health need that interferes with their daily life at home, at school or in the community. Their families are usually trying to figure out what is going on, hoping that a clear diagnosis will open the doors to services that their child needs. They find out that there isn’t a diagnostic tool like a blood test or an x ray and identifying what’s going on can be tricky. Piecing the picture together usually relies on the observations of teachers, family members, doctors and others and their observation skills can vary greatly.
But finally someone does arrive at a diagnosis. Then maybe another. And a different therapist or someone during a hospital stay adds yet another. Parents often ask, If no one can agree on my child’s diagnosis, then how can I ever decide on what treatments or services he (or she) needs?
Treatments for children’s mental health disorders are being studied and evaluated with the goal of matching the most effective treatment to a specific mental health disorder. We are hearing more and more these days about “evidence based practices” in the children’s mental health system. It conjures up the feeling that science and precision will be applied to matching the “right” treatment to any child with a mental health disorder. There is already strong evidence that certain medications are effective for children with ADHD and cognitive behavioral therapy is a promising treatment for children with anxiety or depression.
But therein lies the rub. An accurate picture of what is going on for a child with mental health needs is required in order to choose an effective treatment. Therapists sometimes refer to the “art” of diagnosing and in the next breath outline the science of evidence based practice. Perhaps this reflects where we are in the children’s mental health world. Maybe it is morphing too — from a denial not too long ago that children’s had mental health disorders; to a recognition that adult treatments can be ineffective and even unsafe for children; to an interest in studying what truly works for children, youth and their families.
In the meantime, I think we’ll just keep answering those calls.
It’s been 8 or 9 years since I led a parent support group, yet every story, every success and every frustration of each group member has stayed vividly with me . The two groups I ran were for parents like me — their children and teens had mental health needs. They came looking for much more than support. They needed to find elusive resources, locate smart, competent therapists and figure out how to make their child’s school day better. But they got support, too. And it was from parents who had also been blamed for an illness no one seems to quite understand and who persevered until they found a way to improve their lives. And even after they found needed resources, therapists or strategies, most stayed for the support.
When I stopped leading the groups it was as if I’d stopped watching a favorite soap opera. I wanted to know how things turned out and I missed being able to hear each installment. While I’ve heard from one former group member or another intermittently, 2009 was a banner year. This year, I heard from 4 different parents who had attended that group and they wrote to let me know how well their children and families are doing. I was amazed that they could track me down — and wanted to! In these busy times, I was also touched that they took the time to send a card or email and made it a priority. Wow, people are just amazing.
First, I got a card last January from a couple that had since moved back to the South. He was in the military and when their then-13
year old daughter began acting out, the base chaplain suggested they apply for services and somehow they also found my group. The children’s mental health world was very different from their military world and they did their best to learn what they needed. Their daughter had just managed to complete treatment when their military transfer came through. And that was the last I expected to hear from them. So when I got a card last year telling me how well the whole family was doing, I was surprised and very pleased.
Over the remaining months of 2009 I heard from three more group members. One emailed to share some resources that she hoped I could pass on to families or use on our web site. She took the opportunity to tell me how her sons were doing and how much the group had meant to her. “You saved our lives,” she wrote. Another emailed about her daughter — who she worried would end up dead, in jail or lost somewhere in the system. But she is now a mother herself and a wonderful mother at that. As she cares for her young son, she tells her own mother that she learned how to nurture “when you thought I didn”t notice.” This fomer group member wrote that her grandson is now in preschool and loves it! When her daughter thanked her for helping her with his IEP, she wrote, “I couldn’t help quietly thanking you for all your support through the years.”
In November I got another unexpected email. This mom had attended the group and always stopped the conversation when she announced that she had 6 daughters. I think we were all imagining what the laundry must be like! She wrote that the daughter who was “my reason for coming to the meetings” was taken off all her meds when she was 18 and was thought to have been misdiagnosed. Her life has changed dramatically and she is now happily married with 3 children. She ended her email by writing, “I just was thinking of you and decided to look you up and say hi.”
Those parents in my long ago group and hundreds of thousands of others are searching for professional supports and treatments. And they should But I think that we underrate how much impact a support group and an ongoing supportive relationship with peer — in this case other parents — can have. There’s only one study that I’ve found about the value of support groups (that study concludes that parents who attend support groups seek out a greater range of services) but of course, it’s a topic that’s rarely studied.
So anecdotal information will have to do. So many services are short term, intensive and focused on the child yet it’s parent support that is often a lifeline and helps the family build a bridge with new skills and needed information. It’s hard to measure how important groups can be, but for the 4 people above, they certainly have made a difference.
Have a great 2010!!