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Journal of Clinical Psychology in Medical Settings, Vol. 5, No. 3, 1998

The Effect of Racial and Ethnic Diversity on theDelivery of Mental Health Services in PediatricPrimary Care

Stephanie Irby Coard1'3 and E. Wayne Holden2

The effects of racial and ethnic diversity on the detection and management of behav-ioral and emotional problems in pediatric primary care are addressed. Serviceaccess and utilization as a function of race and culture are initially examined.Important barriers within pediatric training including minimal emphases onbehavioral training and the limited supply of minority physicians areunderscored. The impact of ethnicity on the development and maintenance ofthe clinical relationship that is critical to accurately and sensitively identifyingand managing behavioral and developmental problems is briefly addressed.Recommendations for further integration of racial/ethnic issues into mentalhealth service provision within the pediatric primary care arena are presented.

KEY WORDS: pediatrics; primary care; mental health; ethnicity.

INTRODUCTION

The utilization of primary care physicians in the identification andtreatment of behavioral and developmental disorders is an important com-ponent to providing effective, comprehensive mental health care services(Holden & Schuman, 1995; Starfield, 1992). Mental Health, United States,1996 (Mandrscheid & Sonnenschein, 1996) released by the SubstanceAbuse and Mental Health Services Administration (SAMHSA), Center for

1New York University Medical Center, Department of Psychiatry, Child Study Center, NewYork, New York.

2Macro International, Inc., Atlanta, Georgia.3To whom correspondence should be addressed at New York University Medical Center,Department of Psychiatry, Child Study Center, 550 First Avenue, New York, New York10016.

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1068-9583/98/09(XM)275J15.00/0 C 1998 Plenum Publishing Corporation

276 Coard and Holden

Mental Health Services (CMHS), estimates that 20% of all children frombirth through 17 years of age suffer from a diagnosable mental, emotional,or behavioral disorder. Furthermore, the report estimates that, of 33 millionchildren and adolescents from age 9 to age 17 years, 3.5 million to 4.0million (9% to 13%), suffer from a serious emotional disturbance. Thismay include the range of diagnosable emotional, behavioral, and mentaldisorders that can severely disrupt a child's daily functioning in home,school or community. However, it has been estimated that only 1% to 2%of children and adolescents are treated by mental health specialists(Costello, Burns, Angold, & Leaf, 1993).

Clearly, too many children and adolescents in the United States sufferfrom mental disorders which are unrecognized, misdiagnosed, and under-treated. The current childhood mental health delivery system, which focusesprimarily on referrals into tertiary care, cannot adequately identify and pro-vide effective services to this large population. An integrated system of carein which health care, mental health, and educational systems work collabo-ratively to develop and improve service delivery is warranted. Within thisframework, effective utilization of aspects of health care delivery such aspediatric primary care is critical. The pediatrician is often the first to iden-tify behavioral and developmental problems, as well as to initiate attemptsat mental illness prevention (Fontanesi, 1997).

In the last two decades, increased attention has been placed on theprevention, early detection, and management of the various behavioral, de-velopmental, and social functioning problems encountered in pediatric prac-tice (American Academy of Pediatrics, 1982; Haggerty, Roghmann, & Pless,1975). While these problems are by no means "new" and have always af-fected children, many have become more prevalent. For example, the num-ber of children and adolescents with activity limitations caused by a chronichealth condition with attendant psychological problems currently approaches20% (American Academy of Pediatrics, 1993a). The suicide rate for maleadolescents has doubled since 1960, and exposure of children to either do-mestic violence or community-based violence has reached epidemic propor-tions (U.S. Children and Their Families, 1989). Because of the prevalenceof these problems and as part of ongoing health care, the pediatrician isbeing asked to expand the traditional role of health supervision and man-agement of physical illness to address psychosocial and behavioral problemsmore effectively. Pediatricians have also become increasingly engaged in di-rect intervention designed to change behavior in their patients. This includesinvolvement in the pharmacological management of children with disruptivebehavior disorders such as attention deficit hyperactivity disorder (Culbert,Banez, & Reiff, 1994; Reiff, Banez, & Culbert, 1993), as well as the iden-tification and subsequent management of children with specific educational

The Effect of Racial and Ethnic Diversity 277

problems (Altemeier, 1997). While these changes have occurred graduallyover the last two decades, they become more important as the general healthcare system becomes dominated by managed care and other structuralchanges designed to improve efficiency (Fontanesi, 1997).

The large percentage of children who need mental health services, butwhose problems and service needs are not being met, is further complicatedby issues related to race, ethnicity, culture, and the barriers to access andutilization of health and mental health services experienced by minoritygroups. It is of particular importance to understand clearly the efficacy ofmental health service provision in the context of pediatric primary care withnon-white racial/ethnic groups (Tarnowski, 1991; Tarnowski & Rohrbeck,1993). The demographic profile of the pediatric population is changing morerapidly than that of society as a whole. The rapid growth of children ofcolor puts pediatricians on the front lines of culturally sensitive care. Whilerace itself should not be construed as a health or mental health determinant,it should be understood as a proxy for adverse environmental and socialconditions perhaps affecting non-Whites at low income levels more stronglythan Whites at identical income levels (Freeman, 1990). Children of colorare at significant risk of long-term impairment in developmental outcomes,resulting in increased behavioral morbidity that may place limits on theirpotential functioning as adults. Early identification and intervention with mi-nority children within the context of pediatric primary care would facilitatethe provision of mental health services during periods where greater poten-tial exists for fully enhancing developmental trajectories.

This paper examines the role of race and ethnicity in the detectionand management of mental health disorders in pediatric primary care andprovides recommendations for the roles of psychologists. The first portionof the paper is devoted to a review of research on service access and utili-zation as a function of race and culture. This is followed by an examinationof the underrepresentation of minorities in primary care as an importantfactor influencing detection rates and subsequent management. The influ-ences of ethnicity on the development and maintenance of the clinicalrelationship will then be addressed. Finally, recommendations for furtherintegration of racial/ethnic issues into mental health service provision withinthe primary care arena are presented.

In this paper, culture is defined as the transmission of knowledge, skills,attitudes, behaviors, and language from one generation to the next, usuallywithin the confines of a physical environment. According to this view cul-ture is a learned behavior. Similarly, Smedley (1993) points out that cultureis learned, not inherited, and that one learns how to behave and thinkduring the process of development in a particular society. The term ethnicityrefers to a group with a specific national origin, religious affiliation, or


other type of socially or geographically defined group. However, in theUnited States, ethnicity has been used as a euphemism for race when re-ferring to people of color and as a nonracial designation for Whites(Betancourt & Lopez, 1993). Race is defined as a concept that refers to apresumed classification of all human groups on the basis of biological orvisible physical traits (e.g., skin color, physical features), behavioral patterns,and, in some cases, language.

SERVICE ACCESS AND UTILIZATION AMONGMINORITIES

As American society becomes increasingly multicultural, the challengeof meeting youth mental health needs requires increased attention to eth-nicity. To maximize effectiveness, we need to learn how children's ethnicityrelates to their access to and utilization of mental health services. Under-standing this relationship, and the variations therein, may help usunderstand attitudes and concerns that families of different ethnic groupsbring to the assessment and intervention process and may suggest hypothe-ses as to why some children receive needed mental health care more readilythan others. The resulting knowledge may, in turn, improve the identifica-tion and management of behavioral and developmental problems inpediatric primary care in children of color by enhancing alliance formationwith families and reducing barriers to care across the diverse componentsof these populations.

The widening disparity in the physical and mental health status betweennon-minority children and minority children has received considerable at-tention during the past few years. In fact, many of the U.S. Public HealthService's "Healthy People 2000 Objectives" were intended to address thehigh concentration of disease and disability among racial and ethnic minoritypopulations (Stoto, Behrens, & Rosemont, 1990). Although many wouldagree that such issues are important, experts acknowledge that we knowvery little about utilization of mental health for children of different ethnicgroups (Hoperman, 1992). Even the current knowledge base on mentalhealth utilization by children in our largest minority groups—African Ameri-can and Latino—is quite thin (Boyd-Franklin, 1989; Bui and Takeuchi, 1992;Cheung & Snowden, 1990; Franklin, 1982; Gary, Leasjpre, Howard, & Buck-nell-Dowell, 1983; Jellinek and Murphy, 1988; Macro International, 1992;McLoyd, 1990; Saunders, Resnick, Hoberman, & Blum, 1994; Snowden &Cheung, 1990), and there is little research on these children's patterns ofentry into mental health facilities (Hoperman, 1992; Takeuchi, Bui, & Kim,1993; Weiz & Weiss, 1993). In short, patterns of service utilization have


focused on adults, neglecting the mental health needs of children and ado-lescents, particularly those of color. Our limited information in this areamakes it necessary to extrapolate from adult data or from areas of the lit-erature that may bear on the experiences of these children and their mentalhealth.

There is also surprisingly little child-focused research on mental healthservice access. What we do know, however, is that minority children haveless access to health care, independent of their health status, sex, economicstatus, health insurance status, and place of residence (Wood, Hayward,Corey, Freeman, & Shapiro, 1990). Determining the scope of the prob-lem—the number of children of color who need, or are likely to becomeneedy of, assessment and/or intervention for mental health disorders pre-senting in primary care—is not a simple matter. Estimating the prevalenceof psychological disorders among groups of children is an inexact measureat best. Furthermore, in any discussion of mental health problems amongchildren of color, it is necessary to recognize that race influences thosefactors that contribute to behavioral and emotional disorders as well asthose that affect the duration and severity of an illness (Chunn, Dunston,& Ross-Sheriff, 1983). While research on minority mental health has docu-mented the numerous ways in which ethnicity influences the psychologicalwell-being of minority adults and families, less attention has been paid toits influence on the developing child and adolescent. For example, howethnicity influences the child's manifestation of characterological and so-matic symptoms, and how patterns of illness and dysfunction may beculturally reinforced and tolerated are not well understood.

There are several related lines of theory and research that have heu-ristic value. For example, some prominent theories of health behavior focuson the interpsychic and intrapsychic dynamics of help-seeking. One relevantnotion is that when parents come to perceive that their child may have aproblem, they test that perception against the views of others in their en-vironment—family members, friends, and/or professionals (Fiese &Sameroff, 1989; Romero, 1983). It may be that parents reach a certain levelof anxiety with respect to the problem, and then others are consulted torelieve that anxiety. In support of this theory, Weisz and colleagues, focus-ing on southeast Asian, Jamaican, and American populations, have foundevidence of intercultural differences in adults' "distress thresholds" withrespect to children's behavioral and emotional problems (Lambert et al.,1992; Weisz, 1989; Weisz et al., 1988, 1998; Weisz & Weiss, 1991). Adultsof different cultural backgrounds were reported to differ in the degree towhich they consider the same child problems serious, unusual, and likelyto improve in the absence of professional intervention or whether variouschild problems warrant a referral (McMiller & Weisz, 1996; Weisz and


Weiss, 1991). Intercultural differences of these various types obviouslymight be associated with differences in adults' pattern of help-seeking withrespect to children. Given that pediatric primary care providers appear tobe more adept at identifying behavioral and emotional impairment whenit is most severe and when parents directly express concerns regarding be-havioral and emotional functioning (Holden & Schuman, 1995), suchintercultural differences are likely to impact upon detection and manage-ment of mental health in the primary care setting.

Financial resources related to ethnic group membership may also in-fluence adults patterns of help-seeking. Several sources indicate thatfinancing mental health care is a significantly greater problem for familiesof African American and Latino children than for the families of their Cau-casian counterparts (Aday, Fleming, & Andersen, 1984; Aday et al., 1993;Macro International, 1992; Padget, Patrick, Burns, Schlesinger, & Cohen,1993; U.S. Congress Office of Technology Assessment, 1991). To the extentthat minority-group parents are concerned about their ability to financeprofessional services, they might well be reluctant to contact professionalsearly on as they consider what to do about their child's problems (Briones,Heller, & Chalfant, 1990).

The presentation of mental and behavioral illnesses varies among dif-ferent cultural groups. For many cultures, including Middle Eastern, Latino,and Asian, mental illness is severely stigmatized, and many patients presentwith somatic manifestations of mental illness (Welch & Feldman, 1997). Chi-nese families, for example, may be embarrassed to have family members(particularly children) with mental health problems, since this may representa "loss of face" for the family. Parental concerns about the emotional impactof professional services may also enter the picture. Some evidence suggeststhat minority group parents tend to perceive that seeking the services of amental health professional increases the risk that family members will beinappropriately labeled, medicated, or hospitalized (Staggers, 1987). A wari-ness of professionals and agencies might well translate into a reluctance tocontact such sources of help or advice. In support of this view, Hall andTucker (1985) found in a survey of school teachers that African-Americansendorsed counseling for a child's problem far less than for Caucasian chil-dren (Frabreg, Ulrich, & Mezzich, 1993; Staggers, 1987; Takeuchi et al.,1993). Furthermore, African American and Latino youngsters have higherrates of premature termination of therapy than Caucasians (Sue, Fujino, &Rakeuchi, 1991; Takeuchi et al., 1993; Viale-Val, Rosenthal, Curtiss, & Ma-rohn, 1984). By one report, 52.1% of African Americans withdraw, com-pared with 29.8% of Caucasians (Sue, 1977). These statistics underscore theimportance of adapting interventions to the culturally determined prefer-ences and expectations of the client.


Since African American and Latino parents are more reluctant thanCaucasian parents to seek advice and assistance from mental health andagency professionals when their children have behavioral or emotionalproblems (McMiller & Weisz, 1996), language must also be considered asa possible determinant of decreased professional contact. Linguistic minori-ties including Latinos constitute roughly 14% of the U.S. population, andalmost half speak a language other than English in their home. Thirty-ninepercent of Spanish-speaking minority children aged 5 to 17 in the UnitedStates speak a language other than English at home (U.S. Bureau of theCensus, 1990). Particularly in the Latino community, the lack of Englishproficiency may partly explain why parents research the topic within thecommunity before seeking professional help. To some extent, this mightalso be true for African Americans, given the prevalence of Black EnglishVernacular, an English dialect that differs from Standard American English(Pinker, 1994), which is spoken by many African Americans, particularlyyouth. Similarly, some immigration groups may pose particular challengesfor the health care provider when differing communication styles hindersuccessful clinical assessment and management (Welch & Feldman, 1997).

The problems that minorities face in obtaining access to health careare severe and complex. While it is generally agreed that poverty and re-lated socioeconomic factors are a great source of disparity in health statusbetween Whites and minorities (McLoyd, 1998), there is increasing atten-tion to the idea that problems with access are caused not only bysocioeconomic factors, but also by different cultural attitudes and beliefsabout health and medicine. Minorities are known to delay seeking healthcare within the traditional health care system, preferring to rely upon fam-ily, friends, and even spiritualists and healers, during periods of economicand emotional stress. Unique value systems, together with medical care ex-penses, may prevent minorities from utilizing the health care system. Sincedifferent loci of control are operating among many groups and individualsof color, different health promotion strategies should be used to reachthem. Eliminating barriers to care-seeking and behavior change will requirenew, culturally sensitive approaches to information dissemination, healthplanning, and resources management, and may even require the institu-tionalization of new health policies.

TRAINING AND PERSONNEL BARRIERS FORPEDIATRICS

While primary care pediatricians have a central role in providingscreening, preventive, and supportive services to children and adolescents,


pediatric residency training is focused on major physical illness in tertiarycare hospitals and, to a limited degree, on behavioral issues (Holden &Schuman, 1995). Furthermore, while training in ambulatory settings has ex-panded, training in behavioral pediatrics remains limited in many residencyprograms. In 1987, the Residency Review Committee added a requirementfor behavioral teaching, although the specific time requirement for trainingin behavioral pediatrics is undefined (American Academy of Pediatrics,1993). Consequently, many pediatricians have completed training with lim-ited instruction in psychosocial issues. Expanding developmental,behavioral, and adolescent training during residency would better equip pe-diatricians to address the "new morbidity" (i.e., various behavioral,developmental, and social functioning problems encountered in pediatricpractice).

Even the pediatrician with a well-rounded education experiences timeconstraints and inadequate reimbursement for the effort required to addressbehavioral problems. Other barriers for pediatricians in the identificationand subsequent management of behavioral and developmental problemshave included mental disorder classification systems that do not adequatelydescribe the types of psychosocial and behavioral problems encountered bypediatricians, increasing reliance on pathology-based models for screeningmental health problems, and the pediatrician's potential area of competencebeing greater than mere screening for major mental disorders (Jellinek &Murphy, 1988). A comprehensive model integrating those issues and con-sidering aspects of adjustment and adaptation among children and familiescan assist physicians. The Primary Care version of the Diagnostic and Sta-tistical Manual of Mental Disorders (DSM-IV-PC; American Academy of Pe-diatrics, 1996) incorporates a developmental perspective and categorizesnormal variation and problems as well as mental health disorders(Fleischman, 1991). It attempts to link normative, transient variations to at-risk conditions and diagnosable disorders to provide a continuum for serv-icing developmental psychopathology. The challenge still exists to distinguishthose behaviors considered abnormal among one racial/ethnic group but notalways by members of another racial/ethnic group using DSM-PC.

The underrepresentation of certain racial and ethnic minority groupsamong the supply of health care personnel is a persistent dilemma. Whileboth minority and nonminority providers are required to serve the needsof a diverse population, the small numbers of minority heath care providersmay be a factor in the poorer health and mental health status of racial/eth-nic minority populations compared with the nonminority population. Byincreasing the number of minority physicians, at least one barrier (that ofcultural sensitivity) that families have experienced attempting to access thehealth care system may be lessened (U.S. Department of Health and Hu-


man Resources, 1990). That approach, while somewhat limited, has its ad-vantages: a relative increase in the number of minority providers, anincreased awareness and sensitivity to needs of minority trainees by edu-cational institutions, and an emergence of multiple social and communitycare delivery systems. The most serious limitation, however, is the clearlack of responsibility of educators and institutions to provide all traineeswith the necessary minority content to accurately service patients of color(Chunn et al., 1983).

With the exception of Asian physicians, minorities are markedly un-derrepresented in all medical specialties including pediatrics. According tothe American Academy of Pediatrics Department of Research (AmericanAcademy of Pediatrics Committee on Career and Opportunities, 1993),2.7% of all pediatricians are African American, non-Hispanic, 0.1% areAmerican Indian or Alaskan Native, 15.7% are Asian or Pacific Islander,and 5.3% are Hispanic, compared with 75.9% who are Caucasian, non-Hispanic. These figures are approximations based on the 1991 AmericanMedial Association Physician Masterfile and do not include residents. Fur-thermore, while the number of African American pediatric residentsincreased between 1978 and 1990 from 274 to 363 (Rowley, Baldwin, &McGuire, 1991), the growth remains slow and the total numbers low. Be-cause of the scarcity of minority health care providers, most people fromminority populations receive health care from practitioners from other ra-cial/ethnic groups. Some have observed that increasing the number ofunderrepresented minority health care providers increases the availabilityof health care providers to low-income and minority populations, who tra-ditionally have had difficulty in obtaining adequate health care (Hanft &White, 1987; U.S. Department of Health and Human Services, 1985a,1988b).

Increasing the number of minority health care providers has the po-tential to increase access for minority populations, thereby offsetting someof the difficulties that minorities have experienced in obtaining adequatehealth care (U.S. Department of Health and Human Services, 1990). Mi-nority physicians are more likely to locate and practice in medicallyunderserved and impoverished areas, and to serve low income patients(Lloyd, Johnson, & Mann, 1978; Keith, Bell, Swanson, & Williams, 1985;U.S. Department of Health and Human Services, 1985b). They are alsomore likely to be sensitive to the culture of their minority patients, therebyhaving the potential to deliver health care services more effectively (Keithet al., 1985; Jones & Flowers, 1990). Furthermore, minority pediatricianshave a unique opportunity to serve as role models, influencing childrenand adolescents to choose careers in medicine. The relatively small num-bers of underrepresented minority health professionals not only lessens


their availability to provide care to their communities, but diminishes theiravailability to participate as faculty in schools that train minority healthprofessionals and to work as scientists and researchers in studying problemsthat affect their communities. As psychologists, we do know that the pres-ence of minority faculty at the internship level is related to higher levelsof exposure to and involvement in multicultural training (Ricardo &Holden, 1994).

Support for the implementation of methods to ensure that more mi-nority medical students choose primary care pediatrics is warranted. Whilemore minority pediatricians will not in and of itself solve the problem oflack of access to care for minority children, more caring, concerned phy-sicians who are involved in primary care and providing health care forminority infants and children can positively affect the health status of mi-norities (Pinn-Wiggins, 1990).

RACE/ETHNICITY, CLINICAL PRESENTATIONS, ANDTHE CLINICAL RELATIONSHIP

To design effective interventions to prevent, detect and manage mentalhealth problems among children of color, the social, economic, genetic, be-havioral, and cultural factors that differentiate racial/ethnic groups and themajority population must be more clearly understood. Ethnic minoritiesdisplay a disproportionate prevalence of factors known to be associatedwith poor health and mental health status. These factors may account formost, if not all, of the observed differences in health and mental healthstatus. Others, however, believe that additional genetic and cultural com-ponents affect health and mental health status. Some contend that raceand ethnicity should be given greater weight in planning interventions, andhave shown that socioeconomic variables cannot explain all the differencesbetween Blacks and Whites (Haan, Kaplan & Camacho, 1987; U.S. De-partment of Health and Human Services, 1987).

To effectively address the behavioral and emotional problems of chil-dren of color, the pediatric primary care provider must be cognizant ofindividual as well as ecological approaches to prevention and treatment.Since behavior is embedded within multiple systems that affect behaviorboth directly and indirectly, interventions should focus simultaneously onchildren's individual behavior and on dysfunctional microsystem or meso-system relationships. In addition, cultural dimensions of the family willinfluence the individual's interpretation of and response to these interven-tions. Interventions must simultaneously address ethnic/cultural differencesas well as variables directly related to poverty.


If children have a social factor believed to place them at higher riskfor mental health problems, they are much more likely to receive a mentaldisorder diagnosis (Riley et al., 1993). For example, in the study by Costelloand associates (1988), children independently diagnosed as having a psy-chiatric disorder were more likely to also be identified by their physicianas having a mental disorder if they were an African American, male, andin the lowest third of the socioeconomic structure. Because the social ecol-ogy of African American children as a group includes risk factors such aspoverty and racial oppression, it is reasonable to predict that AfricanAmerican children will be over represented among children with psycho-logical problems (Comer, 1985). In fact, a classic New York study reportedthat proportionately twice as many Black as White children showed "psy-chiatric impairment" (Langner, Gersten, & Eisenberg, 1974). Vincenzi's(1987) often cited study of Black urban sixth-graders found that 36 percentof the children at one school were at least mildly depressed as evidencedby scores on the Children's Depression Inventory. At a second school, withthree times the number of Aid to Families with Dependent Children re-cipients, the depression rate was doubled that in the first school. Whatlittle data are available do not, however, uniformly endorse the idea thatdisorder rates among Black children are higher than among Whites. In aMidwestern study of personality differences among 433 Black and 897White schoolchildren (Gillum, Gomez-Marin, & Prineas. 1984), Black par-ents rated their sons' levels of aggression, somatization, and sleepdisturbance higher than White parents. Black girls were rated higher onsleep disturbance than White girls. The Missouri Children's Picture series,a personality inventory for children, showed Black boys significantly higherthan White boys on aggression and somatization, and significantly loweron masculinity and maturity. Differences between Black and White girls,however, were not significant. In the same vein, Achenbach and Edelbrock(1981) found, in their normative sample for the Child Behavior Checklist(CBCL), that of 119 items analyzed for demographic differences, only 5showed significant race effects, and all these effect sizes were quite small.In the more recent restandardization of the CBCL, ratings of parents ofdifferent ethnic groups matched for socioeconomic status also showed mini-mal differences (Achenbach, 1991). More recently, however, Dupaul andassociates (1997), in a population-based study of a new measure to assessADHD based on DSM-IV symptoms, reported that African American chil-dren were rated as significantly more hyperactive than were Caucasianstudents. Furthermore, teachers rated African American students higherthan Caucasian students on both the hyperactive-impulsivity and the inat-tention factors across all age ranges represented in this national sample.


The views of ethnic minorities on the definition, etiology, and appro-priate treatment of mental illness differ from those of Western mentalhealth professionals. Flaskerud (1984) reported that members of six ethnicgroups differed significantly from mental health professionals both in la-beling behavior as mental illness and in types of behavior managementrecommended. Minority views of maladaptive behavior were broader thanthose of mental health professionals, including spiritual, moral, somatic,psychological, and metaphysical components. Suggestions for managementof disordered behavior included social, spiritual, economic, vocational, rec-reational, personal, physical, and psychological assistance, while mentalhealth professionals relied on traditional psychotherapeutic and psycho-pharmacological approaches. These findings give some clues to the differingvalue that patients of color may place on various microsystem relationships.The well-prepared service provider needs to be familiar with resources thatcould be made available to the client and family—from traditional churchesand social services groups to social clubs, aid societies, and athletic leagues(Spurlock, 1985)—and the degree to which they enhance the fit betweenpatients of color and mental health interventions.

IDENTIFICATION AND MANAGEMENT AMONGCULTURALLY DIVERSE PEDIATRIC POPULATIONS:

THE ROLE OF PSYCHOLOGISTS

Pediatric psychologists' training and interests make for natural part-nerships with pediatricians concerning the problems that present in primarycare (Drotar, 1995; Holden & Schuman, 1995). Pediatricians have becomeincreasingly open to innovative collaborations with psychologists, particu-larly in the treatment of chronically and terminally ill children and theirfamilies. Psychologists need to promote the practice of psychology in pri-mary care and other health-care settings. Psychologists building coalitionswith other health care associations must be a priority. According to Kazak(1995), collaboration efforts are not just effective, they are also the waveof the future. Furthermore, managed care arrangements typically embracethe multidisciplinary team approach. Recent developments in the area ofmanaged care suggest that more economic and conceptual emphasis willbe placed on the provision of mental health services within pediatric pri-mary care settings in the future (Fontanesi, 1997). Support has also becomeavailable for demonstration projects and outcomes research on the deliveryof cost-effective mental interventions within the context of pediatric pri-mary care at the federal level.


What this will require from psychologists to be successful is an appre-ciation for the primary care context (Starfield, 1992) and the developmentof a true primary care orientation for the delivery of psychological services.Efficient screening and detection methods such as the Pediatric SymptomChecklist (Bishop, Murphy, Jellinek, & Dusseault, 1991; Little, Murphy,Jellinek, Bishop, & Arnett, 1994) that can be administered and interpretedby lower-level medical personnel (e.g., nurse practitioners and physiciansassistants) are strategies that can facilitate the identification of childrenand adolescents in need of early intervention services. Adequate normativeinformation on minority populations and the consideration of potential cul-tural and ethnic biases on responses to screening measures is critical totheir continued utility in the primary care context. Primary care is also animportant venue for the development and implementation of preventiveinterventions and health promotion activities. In addition to activities fo-cused on individual patients and their families, psychologists can also playthe role of systems consultants, helping to organize efficient and effectivesystems of care that address all aspects of the biopsychosocial continuumin children and adolescents. The majority of work in pediatric psychologyhas addressed individual disease entities from a tertiary care orientationand excluded the vast opportunities available to assist children and ado-lescents through maximizing the delivery of non-traditional mental healthservices in primary care.

Psychologists can play a major role in working with providers in thepediatric primary care setting who are in need of a sociocultural frameworkto consider diversity of values, communication styles, and cultural expec-tation in a systemic fashion. They need knowledge and skills formulticultural assessment and intervention. Pinderhughes (1989) has definedthe perspectives, capacities, competencies, and abilities that enable practi-tioners to focus successfully on culture in their work. This includesbecoming comfortable with difference, acquiring the ability to control andchange false beliefs and assumptions, respecting and appreciating the valuesand beliefs of those who are different, thinking flexibly, and behaving flex-ibly. Missed opportunities for accurate detection and management ofbehavioral and developmental problems in children of color will occur whenproviders fail to understand the interaction of culture, gender and sexualorientation on health care seeking and adherence to medical regimens. Fur-thermore, there is a need to develop a conceptual framework to enablehealth care providers to organize, access, and accurately assess the valueand utility of existing and future research involving ethnic and culturallydiverse populations.


CULTURAL COMPETENCE ANDPEDIATRIC PRIMARY CARE

While psychologist's training and interests make for natural partner-ships with pediatricians concerning the unique problems and special needsof children of color in primary care, such collaborations are underutilizedand have yet to reach their full potential. This may be due in part to dif-ferences in professional cultures, roles and boundaries (Drotar, 1995).Nevertheless, developing and maintaining an effective interdisciplinary al-liance is crucial if we are to adequately address the mental health needsof children of color. While pediatricians' knowledge base has expanded withrespect to psychosocial aspects of child and family health (American Acad-emy of Pediatrics, 1993), the specific challenges in working with culturallydiverse populations has not been adequately addressed. Psychologists notonly have the training background to do specialized kinds of assessmentsand interventions, there is also evidence of a commitment (more frequentlyengaged in dialogue and empirical research) understand better the role thatracial and ethnic issues play in a child's emotional, social, and physical de-velopment. A wealth of literature exists that has succeeded in bringing theissues and implications of diversity to the forefront. As a group, psycholo-gists are already taking steps to combat barriers to fairness in mental healthaccess and service. But psychologists can do more to eradicate the problemschildren of color and their families face. As psychologists, we are in a po-sition to assist our medical colleagues with a conceptual framework thatdelineates a process of inquiry and investigation with regards to racial/eth-nic populations. Psychologists should assume high levels of initiative andleadership roles in initiating collaborative relationships. Specifically, we canassist in facilitating the understanding of the needs of children of color,which will in turn improve identification and management of their prob-lems.

To begin to unravel the challenges inherent in cross-cultural encoun-ters with patients, physicians need to take steps toward becoming moreculturally competent (Welch & Feldman, 1997). Cultural competency hasbeen defined as a set of congruent behaviors, attitudes, and policies thatcome together in systems or agencies that enable professionals to work ef-fectively in cross-cultural situations. Providers and institutions can takesteps toward improving cultural competency in health care encounters withthe goal being that of full cultural integration. In doing so, a sensitivity tochildhood mental disorders in children from racial/ethnic groups and in-tensive training in multicultural issues is crucial. Specifically, recognizingethnicity and culture as significant parameters in understanding responseto medical regimes and psychological processes is needed. This includes a


respect for the roles of family members and community structures, hierar-chies, values and beliefs within the family's culture as well as patients'religious and/or spiritual beliefs and values, including attribution and ta-boos, since they affect world view, psychosocial functioning, and expressionsof distress.

An understanding of the interplay/overlap of ethnicity, social class, andadaptation also offers a comprehensive framework for the provider to as-sess the five major domains of functioning of the child or adolescent:individual level of psychosocial adjustment, relationships with family, schooladjustment and achievement, relationships with peers, and adaptation tothe community. There are a number of areas in which variations in indi-vidual ethnic development have significant implications for the child'spsychosocial adjustment and, therefore, implications for identification andmanagement of behavioral and developmental problems. These include ar-eas of physical appearance, affect, self-concept, and self-esteem;interpersonal competence; attitudes toward autonomy; attitudes towardachievement; management of aggression and impulse control; and copingand other defense mechanisms. The provider should always use knowledgeabout a child's ethnic background as a general guide to psychosocial as-sessment but be mindful of the individual child's unique characteristics,situation, symptoms, defenses, and coping strategies.

Clinicians assessing the academic performance of minority childrenshould pay careful attention to their verbal skills (they may have greaterfluency in their native language), their attitudes toward school (the mayfeel stigmatized by placement in a special education class), their motivationfor learning (they may see no relation between school and the "realworld"), their study habits (they may not have a safe and quiet place tostudy at home or a schedule for studying), and their level of family support(their parents may not be able or willing to assist in and reinforce effortsto succeed academically). Since poor academic achievement is more oftena consequence of cultural, social, and/or environmental factors than a lackof ability, a sensitive provider can identify factors that impede the perform-ance of some children of color and can develop an intervention plan toimprove their functioning.

CONCLUSIONS

Though programs in cross-cultural health care are increasing, there ispresently a lack of comprehensive, formal training in cultural competencyin medical school and residency for pediatricians and other health careproviders working in pediatric primary care. Accordingly, few providers


have addressed the biases they bring to patient encounters or about theirown cultural and ethnic background, health and mental health beliefs andpractices. To begin to unravel the challenges inherent in cross-cultural en-counters with patients and colleagues, primary care providers need to takesteps towards becoming more culturally competent.

Multicultural competence in service delivery and the value of diversity,on a larger societal level and the individual level, are crucial to the iden-tification and management of behavioral and developmental problems inchildren of color. Accordingly, this is a value that should be prominent inthe foundations of a health care system and manifest throughout all levelsof operation. This involves integrating culture-specific beliefs and healingpractices with conventional, mainstream treatments and increasing collabo-ration among cultural healers, psychologists, and primary care providers.In this sense, knowledge of different cultures is necessary, as is an under-standing of the patient's unique and personal history of acculturation.Multicultural competence in a helping service can be attained in a varietyof ways, two of which are the recruitment of ethnic providers and the es-tablishment of intercultural teams. With the demography of the populationcontinuing to change and multicultural diversity becoming the rule ratherthan the exception, the rapid development and active dissemination ofthese approaches will be critical to effective and empathic pediatric primarycare within the health care system of the future.

To accomplish this goal, research addressing the issue of ethnic/cul-tural diversity and mental health provision among children in pediatricprimary care is critically needed. The results of specific studies investigatingscreening and detection, preventive intervention and long term manage-ment for children of color will provide essential information for the futuredevelopment of a sensitive and responsive primary care system. We nolonger need to allocate resources to identify the magnitude of the problembut, instead, we need to conduct health services research that identifieseffective and cost efficient solutions. Sustained commitment from fundingresources will be necessary to accomplish this latter goal as the pediatrichealth care system continues to evolve into the next century.

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