Challenges of Implementing Evidence-Based Practices with Youth of Color

Challenges of Implementing Challenges of Implementing Evidence-Based Practices with Evidence-Based Practices with

Youth of ColorYouth of Color

National Juvenile Justice NetworkNational Juvenile Justice NetworkOctober 7, 2008October 7, 2008

Ken Martinez, Psy.D.Ken Martinez, Psy.D.Mental Health Resource SpecialistMental Health Resource SpecialistTechnical Assistance PartnershipTechnical Assistance PartnershipAmerican Institutes for ResearchAmerican Institutes for Research

Washington, D.C. / Corrales, N. M.Washington, D.C. / Corrales, N. [email protected]@air.org

Ken Martinez, Psy.D.Ken Martinez, Psy.D. 22

U.S. PopulationU.S. PopulationU. S. Census Bureau 2008U. S. Census Bureau 2008

White (Non-Hisp)187.7 million 64.9%White (Non-Hisp)187.7 million 64.9%Latino/HispanicLatino/Hispanic 45.5 million 15.1% 45.5 million 15.1%African American 40.0 million 13.2%African American 40.0 million 13.2%Asian AmericanAsian American 15.3 million 15.3 million 5.0% 5.0%American Indian/American Indian/

Alaska Native 4.5 millionAlaska Native 4.5 million 1.5% 1.5%Native Hawaiian Native Hawaiian and other Pacific and other Pacific

IslanderIslander 1.0 million .3% 1.0 million .3%People of Color >106 million 35.1%People of Color >106 million 35.1% (Not counting all other ethnic/racial groups)(Not counting all other ethnic/racial groups)


Projected Rate of Increase of Youth of Projected Rate of Increase of Youth of Color in U.S. from 1995-2015Color in U.S. from 1995-2015

American Indian/ American Indian/ Alaska Native Alaska Native +17%+17%

African AmericanAfrican American +19% +19%

Hispanic/LatinoHispanic/Latino +59%+59%

Asian American, Asian American, Native Hawaiian Native Hawaiian and other Pacific and other Pacific IslandersIslanders +74%+74%

Caucasian/WhiteCaucasian/White - 3%- 3%


Dynamic Ecological Context to ConsiderWhen Developing, Adapting, Choosing

and Using EBTs/ESTs with People of Color

Historical

Values

Contextual

Transactional

Child/Family

Transactional

Best Practices for

Diverse Communities

Methodological


Methodological•Paradigm/Conceptualization•Epistemology

•Empirical•Non-empirical

QualitativePluralistic

•Efficacy vs. Effectiveness•Definition of evidence

•By whom•Using what standard•Compared to what

•Research approach•Traditional (Top down)•Community defined (Bottom up)

•Data collection/analysis/interpretation•Translation•Clinician/Consumer match

ValuesCultural beliefs•Spirituality•Religion•Concepts of:

•Family•Respect •Communal vs. Individualistic•Cooperation vs. Competition•Interdependence vs. Independence

•Rituals•Traditions•World view

Domains and Variables

Transactional •Language•Engagement•Synchronous goals•Relationship•Engaging youth, families, & consumers in research•Availability of providers

Contextual •SES•Immigration status•Generation in US•Degree of political power•Transnationalism•Geographic region•Cultural knowledge•Acculturation level•Self-identified cultural identity•Heterogeneity within ethnic gp•Respect for community knowledge•Setting•Age

Developing, Adapting, Choosing

and Using Evidence Based

Treatments/Empirically SupportedTreatments

Historical•Racism•Ethnocentrism•Colonialism•Displacement•Genocide•Slavery•Prejudice•Discrimination•Exploitation


Dizzying DefinitionsDizzying DefinitionsEvidence Based Practices Evidence Based Practices (EBPs)(EBPs)

Empirically Supported Empirically Supported Treatments (ESTs)Treatments (ESTs)

Evidence Based Evidence Based Treatments (EBTs)Treatments (EBTs)

Cultural Adaptations of Cultural Adaptations of EBPsEBPs

Practice Based Evidence Practice Based Evidence (PBE)(PBE)

Community Defined Community Defined Evidence (CDE)Evidence (CDE)


ESTs/EBTs and EBPsESTs/EBTs and EBPs

ESTs/EBTs: Refer to empirically-derived ESTs/EBTs: Refer to empirically-derived interventions, for specific symptoms or interventions, for specific symptoms or behaviors, that are based upon randomized behaviors, that are based upon randomized controlled trials (RCTs) using a control controlled trials (RCTs) using a control group and an experimental group to prove group and an experimental group to prove their “efficacy” in a controlled setting and in their “efficacy” in a controlled setting and in some cases. They use a strict manualized some cases. They use a strict manualized approach under scientifically controlled approach under scientifically controlled conditions to ensure “fidelity” to the model. conditions to ensure “fidelity” to the model. EBPs: “A set of practices that may, or may EBPs: “A set of practices that may, or may not include, an EST/EBT not include, an EST/EBT andand other other interventions or supports and services that interventions or supports and services that also contribute to successful outcomes for also contribute to successful outcomes for children, youth, families and consumers.” children, youth, families and consumers.” (Martinez, 2007)(Martinez, 2007)


Special Analysis for Surgeon General’s Special Analysis for Surgeon General’s Report on Culture, Race and EthnicityReport on Culture, Race and Ethnicity

The 2001 Surgeon General’s Supplement Report on The 2001 Surgeon General’s Supplement Report on Mental Health: Culture, Race and Ethnicity found very Mental Health: Culture, Race and Ethnicity found very little empirical evidence regarding outcomes of mental little empirical evidence regarding outcomes of mental health care for ethnic/racial groups health care for ethnic/racial groups (Miranda, et al., 2003)(Miranda, et al., 2003)

Between1986 and 2001 nearly Between1986 and 2001 nearly 10,00010,000 participants have participants have been included in randomized controlled trials evaluating been included in randomized controlled trials evaluating the efficacy of interventions for four mental health the efficacy of interventions for four mental health conditions (bipolar disorder, schizophrenia, depression conditions (bipolar disorder, schizophrenia, depression and ADHD) and only and ADHD) and only – 561 African Americans561 African Americans– 99 Latinos99 Latinos– 11 Asian Americans and Pacific Islanders11 Asian Americans and Pacific Islanders– 0 American Indians and Alaska Natives 0 American Indians and Alaska Natives

were available for analysis. were available for analysis. (Miranda et al., 2003)(Miranda et al., 2003)


Cultural Adaptations of ESTs/EBTsCultural Adaptations of ESTs/EBTs

Some great examples:Some great examples:– Guiando a Ninos Activos (GANA) Guiando a Ninos Activos (GANA)

a cultural adaptation of Parent a cultural adaptation of Parent Child Interaction Therapy-PCIT Child Interaction Therapy-PCIT (Kristen McCabe)(Kristen McCabe)

– For Native American children and For Native American children and youthyouth

Honoring Children, Mending the Honoring Children, Mending the Circle (Trauma Focused Cognitive Circle (Trauma Focused Cognitive Behavioral Therapy)Behavioral Therapy)Honoring Children, Respectful Ways Honoring Children, Respectful Ways (Treatment for Children with Sexual (Treatment for Children with Sexual Behavior Problems)Behavior Problems)Honoring Children, Making Relatives Honoring Children, Making Relatives (PCIT) (PCIT)

– Honoring Children Series by Dee Honoring Children Series by Dee BigFoot at the Indian Country Child BigFoot at the Indian Country Child Trauma CenterTrauma Center


Practice Based EvidencePractice Based Evidence

““A range of treatment approaches and A range of treatment approaches and supports that are derived from, and supports that are derived from, and supportive of, the positive cultural supportive of, the positive cultural attributes of the local society and attributes of the local society and traditions…[they] are accepted as traditions…[they] are accepted as effective by the local community, effective by the local community, through community consensus, and through community consensus, and address the therapeutic and healing address the therapeutic and healing needs of individuals and families from a needs of individuals and families from a culturally-specific framework…” culturally-specific framework…” (Isaacs, (Isaacs, Huang, Hernandez, Echo-Hawk, 2006)Huang, Hernandez, Echo-Hawk, 2006)

Practice based evidence is a set of Practice based evidence is a set of practices that are unique and inherent practices that are unique and inherent in a culture that have proven to be in a culture that have proven to be effective based upon community effective based upon community consensus.consensus. (Martinez, 2007)(Martinez, 2007)


CautionsCautionsEthnic/racial groups “Ethnic/racial groups “are largely missing from the efficacy studies that make up the evidence base for treatments…well-controlled efficacy studies examining outcomes of mental health care for [ethnic/racial gps] are rarely available…There is There is some, some, albeit limitedalbeit limited research, that research, that somesome ESTs are appropriate ESTs are appropriate for for somesome ethnic groups ethnic groups (Miranda et .al., 2005)(Miranda et .al., 2005)

Most ESTs and EBTs are conducted with Most ESTs and EBTs are conducted with White, educated, verbal and middle class White, educated, verbal and middle class individuals and may not generalize to individuals and may not generalize to ethnic/racial groups and third world ethnic/racial groups and third world communitiescommunities (Bernal & Scharron-del-Rio, 2001)(Bernal & Scharron-del-Rio, 2001)

We should be concerned about the “dogmatism We should be concerned about the “dogmatism of an exclusive ideology” Imposition of EBTs on of an exclusive ideology” Imposition of EBTs on another cultural group can be considered a new another cultural group can be considered a new form of “cultural imperialism”form of “cultural imperialism” (Bernal & Scharron-del-Rio, 2001)(Bernal & Scharron-del-Rio, 2001)


Everything Belongs, But ExamineEverything Belongs, But ExamineIt’s Cultural Appropriateness CarefullyIt’s Cultural Appropriateness Carefully

ESTs/EBTs/EBPs/Cultural ESTs/EBTs/EBPs/Cultural Adaptations, Practice Based Adaptations, Practice Based Evidence, CDE Evidence, CDE all belongall belong, but…, but…All must be examined for their cultural All must be examined for their cultural assumptions/biases in their assumptions/biases in their epistemology, design (cultural world epistemology, design (cultural world view), standardization and replication; view), standardization and replication; Translations are not enoughTranslations are not enoughExamples of EBPs that were Examples of EBPs that were developed for Latino youth and have developed for Latino youth and have been found to work:been found to work:– Brief Strategic Family TherapyBrief Strategic Family Therapy– Family Effectiveness TrainingFamily Effectiveness Training

(Santisteban, Perez-Vidal, Coatsworth, Kurtines, (Santisteban, Perez-Vidal, Coatsworth, Kurtines, Schwartz, LaPerriere, Szapocznik, 2003)Schwartz, LaPerriere, Szapocznik, 2003)


An Alternative: Community An Alternative: Community Defined Evidence (CDE)Defined Evidence (CDE)

Community Defined Community Defined Evidence Evidence – A set of practices that communities A set of practices that communities

have used and determined to yield have used and determined to yield positive results as determined by positive results as determined by community consensus over time community consensus over time and which may or may not have and which may or may not have been measured empirically but have been measured empirically but have reached a level of acceptance by reached a level of acceptance by the community. the community. (CDEP Working Group, 2007)(CDEP Working Group, 2007)

CDE includes world view, contextual CDE includes world view, contextual aspects and transactional processes aspects and transactional processes that do not limit it to one manualized that do not limit it to one manualized treatment but is usually made up of a treatment but is usually made up of a set of practices that are culturally set of practices that are culturally rooted - A supplemental approachrooted - A supplemental approach


ConclusionsConclusionsProceed with extreme caution in “off the Proceed with extreme caution in “off the shelf” use of ESTs/EBTs with youth of color shelf” use of ESTs/EBTs with youth of color

Use an EST/EBT with those youth and Use an EST/EBT with those youth and families on whom it was developed or families on whom it was developed or standardizedstandardized

ESTs/EBTs may work with youth and ESTs/EBTs may work with youth and families of color but they need to be families of color but they need to be tested (standardized on them) to prove tested (standardized on them) to prove whether they do or don’twhether they do or don’t

Consider Consider ESTs/EBTs/EBPs/CA-EBTs/PBE/CDE all as ESTs/EBTs/EBPs/CA-EBTs/PBE/CDE all as options for ethnic/racial populations, options for ethnic/racial populations, with with cautions;cautions; Consider historical trauma, values/ Consider historical trauma, values/ beliefs, contextual, transactional, linguistic beliefs, contextual, transactional, linguistic and methodological variables/issues when and methodological variables/issues when choosing and using themchoosing and using them


ConclusionsConclusionsEBPs (ESTs/EBTs) are not a panacea; there is room for EBPs (ESTs/EBTs) are not a panacea; there is room for other interventions and for more than one “measuring other interventions and for more than one “measuring stick” to validate practicesstick” to validate practicesInclude and don’t dismiss practices that have “worked” in Include and don’t dismiss practices that have “worked” in communities, even though we still need to document, communities, even though we still need to document, evaluate in culturally responsive ways and validate those evaluate in culturally responsive ways and validate those that work that work Cost is also a consideration for cultural communities since Cost is also a consideration for cultural communities since some ESTs/EBTs are proprietarysome ESTs/EBTs are proprietaryConsider using the full range of Consider using the full range of options that may be available options that may be available without relying totally on without relying totally on website lists of ESTs/EBTswebsite lists of ESTs/EBTs


RecommendationsRecommendationsWhat you can do: -ASK QUESTIONS-What you can do: -ASK QUESTIONS-– Has the EST/EBT been standardized on the particular Has the EST/EBT been standardized on the particular

ethnic/racial group it will be used with?ethnic/racial group it will be used with?– Was it proven to be effective; Was it proven to be effective;

did it work with them?did it work with them?– Is there a cultural match of Is there a cultural match of

intervention to the youth and intervention to the youth and family of color?family of color?

– Can and will the intervention Can and will the intervention be individualized for the youth and family?be individualized for the youth and family?

– Are there other community-defined options that have Are there other community-defined options that have been proven to work with this population in this been proven to work with this population in this community that may be culturally appropriate community that may be culturally appropriate alternatives?alternatives?

– Have cultural/community leaders been involved in Have cultural/community leaders been involved in selecting culturally appropriate interventions?selecting culturally appropriate interventions?


RecommendationsRecommendations

MORE QUESTIONS TO ASK:MORE QUESTIONS TO ASK:– Is the practice proprietary? (How much does it cost to sustain Is the practice proprietary? (How much does it cost to sustain

over time-will it survive budget cuts?)over time-will it survive budget cuts?)– If it was culturally adapted, was the adaptation based upon the If it was culturally adapted, was the adaptation based upon the

fundamental cultural world view of the population, or was the fundamental cultural world view of the population, or was the intervention just “tweaked” for the ethnic/racial population? intervention just “tweaked” for the ethnic/racial population?

– Was there, at a minimum, a proportional representation of the Was there, at a minimum, a proportional representation of the ethnic/racial group being served in the standardization samples ethnic/racial group being served in the standardization samples and were they of sufficient size to be statistically significant for and were they of sufficient size to be statistically significant for each ethnic/racial group?each ethnic/racial group?

Do what we can to influence policy-makers, funders, Do what we can to influence policy-makers, funders, administrators, clinicians to be open to alternative administrators, clinicians to be open to alternative methods of measurement and intervention that fit methods of measurement and intervention that fit culturally and linguistically culturally and linguistically andand produce desired outcomes produce desired outcomes


What Can You Do as Juvenile Justice What Can You Do as Juvenile Justice Professionals?Professionals?

Unfortunately there is no central place or directory for Unfortunately there is no central place or directory for practice based evidence or community defined evidence practice based evidence or community defined evidence (yet)(yet)Best practice interventions don’t have to be “clinical” ie, Best practice interventions don’t have to be “clinical” ie, they can be psychosocial, psycho-educational they can be psychosocial, psycho-educational (outpatient or institutional parenting program), etc.(outpatient or institutional parenting program), etc.Best practices can be local tooBest practices can be local too– Are there neighborhood/community/cultural practices that have Are there neighborhood/community/cultural practices that have

worked such as mentoring programs, substance abuse worked such as mentoring programs, substance abuse prevention programs, faith-based intervention programs?prevention programs, faith-based intervention programs?

– If so, assist the community/agency/faith based group document If so, assist the community/agency/faith based group document the success-it begins with establishing a documented track the success-it begins with establishing a documented track recordrecord


Be on the look out for…Be on the look out for…

The Guide for Selecting and Adopting Evidence-The Guide for Selecting and Adopting Evidence-Based Practices for Children and Adolescents Based Practices for Children and Adolescents with Disruptive Behavior Disorder with Disruptive Behavior Disorder An Implementation Resource Kit (IRK) to be released by An Implementation Resource Kit (IRK) to be released by SAMHSA, written by NASMHPD Research InstituteSAMHSA, written by NASMHPD Research Institute– Describing 7 multilevel prevention programs and 11 Describing 7 multilevel prevention programs and 11

intervention programs with descriptions of their intervention programs with descriptions of their applicability to populations of colorapplicability to populations of color

– Will include Information Sheets for Families on each Will include Information Sheets for Families on each one to help families select the best one for their youthone to help families select the best one for their youth

– A table describing the ethnic/racial populations that A table describing the ethnic/racial populations that were used in their standardization were used in their standardization


ReferencesReferences

Bernal, G., & Scharron-del-Río, M. (2001). Are empirically Bernal, G., & Scharron-del-Río, M. (2001). Are empirically

supported treatments valid for ethnic minorities? Toward an supported treatments valid for ethnic minorities? Toward an

alternative approach for treatment research. alternative approach for treatment research. Cultural Diversity Cultural Diversity

and Ethnic Minority Psychology, 7and Ethnic Minority Psychology, 7, 328-342. , 328-342.

Bernal, G., Beyond “Bernal, G., Beyond “One Size Fits AllOne Size Fits All”: Adapting Evidence-”: Adapting Evidence-based Interventions for Ethnic Minorities, 2006based Interventions for Ethnic Minorities, 2006

BigFoot, Dolores (Dee) S., Honoring Children Series. Indian BigFoot, Dolores (Dee) S., Honoring Children Series. Indian Country Child Trauma Center, Country Child Trauma Center, www.icctc.orgwww.icctc.org

Community Defined Evidence Work Group, National Network Community Defined Evidence Work Group, National Network to Eliminate Disparities/National Latino Behavioral Health to Eliminate Disparities/National Latino Behavioral Health Association, 2007.Association, 2007.


ReferencesReferencesIsaacs, M.R., Huang, L. M., Hernandez, M., Echo-Hawk, H. Isaacs, M.R., Huang, L. M., Hernandez, M., Echo-Hawk, H. The Road to Evidence: The Intersection of Evidence-Based The Road to Evidence: The Intersection of Evidence-Based Practices and Cultural Competence in Children's Mental.Practices and Cultural Competence in Children's Mental. National Alliance of Multi-Ethnic Behavioral Health National Alliance of Multi-Ethnic Behavioral Health Associations, December 2005.Associations, December 2005.

McCabe, K.M., Yeh, M., Garland, A.F., Lau, A.S., Chavez, G. McCabe, K.M., Yeh, M., Garland, A.F., Lau, A.S., Chavez, G. The GANA Program: A Tailoring Approach to Adapting Parent The GANA Program: A Tailoring Approach to Adapting Parent Child Interaction Therapy for Mexican Americans. Child Interaction Therapy for Mexican Americans. Education Education and Treatment of Children. 28, No. 2,and Treatment of Children. 28, No. 2, 111-129, 2005. 111-129, 2005.

Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, W.C., & Miranda, J., Bernal, G., Lau, A., Kohn, L., Hwang, W.C., &

LaFromboise, T. State of the science on psychosocial LaFromboise, T. State of the science on psychosocial

interventions for ethnic minorities. interventions for ethnic minorities. Annual Review of Clinical Annual Review of Clinical

Psychology, 1Psychology, 1, 113-142, 2005., 113-142, 2005.


ReferencesReferences

Miranda, J., Nakamura, R., Bernal, G. Including Ethnic Miranda, J., Nakamura, R., Bernal, G. Including Ethnic

Minorities in Mental Health Intervention Research: A Practical Minorities in Mental Health Intervention Research: A Practical

Approach to a Long-Standing Problem. Approach to a Long-Standing Problem. Culture, Medicine and Culture, Medicine and

Psychiatry Psychiatry 2727: : 467–486, 2003.467–486, 2003.

Santisteban, D., Perez-Vidal, A. Coatsworth, J.D., Kurtines, Santisteban, D., Perez-Vidal, A. Coatsworth, J.D., Kurtines, W.M., Schwartz, S.J., LaPerriere, A., Szapocznik, J., W.M., Schwartz, S.J., LaPerriere, A., Szapocznik, J., Efficacy of Efficacy of Brief Strategic Family Therapy in Modifying Hispanic Brief Strategic Family Therapy in Modifying Hispanic Adolescent Behavior Problems and Substance Use. Adolescent Behavior Problems and Substance Use. Journal of Journal of Family Psychology. 2003 March; 17(1): 121–133. Family Psychology. 2003 March; 17(1): 121–133.

Slife, B.D., B.J. Wiggins, and J.T. Graham. 2005. Avoiding an Slife, B.D., B.J. Wiggins, and J.T. Graham. 2005. Avoiding an EST monopoly: Toward a pluralism of philosophies and EST monopoly: Toward a pluralism of philosophies and methods. methods. Journal of Contemporary PsychotherapyJournal of Contemporary Psychotherapy 35 (March): 35 (March): 83-97. 83-97.


EBT/EST/EBP WebsitesEBT/EST/EBP Websites

Matrix of Children's Evidence-Based Interventions, Yannaci, J., Rivard, J.C. NASMMatrix of Children's Evidence-Based Interventions, Yannaci, J., Rivard, J.C. NASMHPD Research Institute (NRI), April 2006, HPD Research Institute (NRI), April 2006,

http://www.nri-inc.org/reports_pubs/2006/EBPChildrensMatrix2006.pdfhttp://www.nri-inc.org/reports_pubs/2006/EBPChildrensMatrix2006.pdf

National Child Traumatic Stress Network, National Child Traumatic Stress Network, http://www.nctsnet.orghttp://www.nctsnet.org

National Registry of Evidence-based Programs and Practices (NREPP), National Registry of Evidence-based Programs and Practices (NREPP),

Substance Abuse and Mental Health Services Administration (SAMHSA), Substance Abuse and Mental Health Services Administration (SAMHSA),

http://nrepp.samhsa.gov/index.htmhttp://nrepp.samhsa.gov/index.htm

Oregon Department of Mental Health, Oregon Department of Mental Health,

http://www.oregon.gov/DHS/mentalhealth/ebp/main.shtmlhttp://www.oregon.gov/DHS/mentalhealth/ebp/main.shtml

Resource Guide for Promoting an Evidence-Based Culture in Children’s Mental Resource Guide for Promoting an Evidence-Based Culture in Children’s Mental

Health (SAMHSA) Health (SAMHSA) www.systemofcare.samhsa.govwww.systemofcare.samhsa.gov

SAMHSA EBP Web Guide SAMHSA EBP Web Guide http://www.samhsa.gov/ebpWebguide/index.asphttp://www.samhsa.gov/ebpWebguide/index.asp

Challenges of Implementing Evidence-Based Practices with Youth of Color

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