Journal of Pediatric Psychology, Vol. 27, No. 4, 2002, pp. 309–314
Introduction to the Special Issue: Economic, Health, and Mental Health Disparities Among Ethnic Minority Children and Families Diane J. Willis, PhD University of Oklahoma Health Sciences Center
This special issue of Journal of Pediatric Psychology (JPP) focuses on children from low-income or ethnic minority backgrounds. This population constitutes a large proportion of patients seen by pediatric psychologists, yet we know from reports of the National Institute of Child Health and Human Development (NICHD; 2000) and the Surgeon General (U.S. Public Health Service [USPHS], 2002) that there are significant disparities in health and mental health status for this population. Ethnic minorities are not only subjected to stressful racism and discrimination that can adversely affect health and mental health; they also face greater social and economic inequality and poverty (U.S. Department of Health and Human Services [USDHHS], 2001; Willis, 2000b). The numbers of children living in poverty is far from insignificant (13.5 million), with a large percentage (74%) living in working families. Of these children, 5.8 million live in extreme poverty where the income of families is below $6,500 per year (Children’s Defense Fund, 2000). For instance, on one American Indian reservation, the median income for families is $2,900 per year. Research has demonstrated that children living in poverty are at greater risk for learning, behavioral, and health disorders than children who come from higher socioeconomic families (Aber, Bennett, Conley, & Li, 1997; USDHHS, 1999). Contrary to popular belief, white children conAll correspondence should be sent to Diane J. Willis, Professor Emeritus, University of Oklahoma Health Sciences Center, 4520 Ridgeline Drive, Norman, Oklahoma 73072. E-mail:
[email protected].
2002 Society of Pediatric Psychology
stitute the highest proportion of the population living in poverty, with three out of five poor children being white (8.4 million). However, more than a third of African American (4.2 million) and Hispanic (3.8 million) children are poor (Children’s Defense Fund, 2000). American Indian children constitute another large proportion of the children living in poverty (Willis, 2000a). The NICHD report (2000) states that, in 1996, African American and Hispanic children had a poverty rate four times that of white children and that children from these minority groups who lived in female-headed households were five times more likely to live in poverty than children in two-parent families. The report goes on to state that low-income minority children face great problems in a variety of areas, such as low birthweight, contagious diseases, and childhood injury, all serving to contribute to higher risks for developmental delays and other problems, including death (p. 23). Data about racial and ethnic health disparities from the NICHD report (2000) and Surgeon General’s Report on Mental Health: Culture, Race, and Ethnicity (2001) suggest that six of the ten leading causes of death are behaviorally based—substance abuse, HIV/AIDS, violence, accidents, and diet— making it important for psychologists to focus some of their energies on prevention and early intervention. In this issue, Bachanas et al. address two such behaviorally based disorders. This group described minority adolescents from impoverished environments who are at risk for contracting HIV and at risk for substance abuse. The authors stated, “Teens
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between the ages of 12 and 15, who are engaging in delinquent behavior, using substances, and associating with peers who are engaging in risky behaviors, seem to be at greater risk for HIV and STDs [sexually transmitted diseases], given that they are more likely to initiate sexual activity earlier, have more sexual partners, and practice safer sex less often.” Bachanas et al. suggest that prevention interventions should target minority youths from impoverished backgrounds at much younger ages (i.e., elementary ages) through the schools. Interdisciplinary services at the hospital, with psychologists and others developing prevention-oriented approaches to intervention with these teens, may prevent more serious problems (teen pregnancy, HIV, substance abuse, and mental health problems). Many factors, such as low socioeconomic status (SES), stress, and insufficient social support, increase a child’s risk for disease and disability. Two other articles in this special issue discuss the role of stress and distress on adolescents and ways in which exposure to stressful life events can exacerbate health problems. Gillaspy, Hoff, Mullins, Van Pelt, and Chaney compared adolescents with and without asthma from families below the state poverty level and found that all of the adolescents showed distress but that the adolescents with a chronic health problem (asthma) showed greater distress. Being poor is one risk factor, but being poor and having a health problem increase distress. The authors suggest that attending to health problems alone is insufficient for the well-being of the patient. Screening high-risk populations to assess their level of distress coupled with appropriate medicine and psychological services may, in the long run, enhance the well-being of the patient and reduce health care utilization. Indeed, Brown et al., in their article on home-based asthma education of young low-income children and their families, found that home-based asthma education was effective with very young children (1 to 3 years). Not only did home-based asthma education provide better caregiver quality of life but also the young children had more symptom-free days. Entering the homes of low-income families offers the opportunity to intervene with a variety of problems such as childrearing problems, parental pathology, and so on. Bearison, Minian, and Granowetter, in their article on medical management of asthma and folk medicine in an Hispanic community, remind us that we must always consider cultural beliefs about
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an illness and treatment of the illness. Bearison et al. found a high rate of noncompliance with prescribed regimens in their Dominican population after interviewing the mothers about their thoughts on asthma. The investigators found that the mothers used folk remedies interspersed with prescribed medicine to try to control their children’s asthma. Bearison and colleagues suggested that health professionals need to work with families in a way that reconciles and coordinates both of these treatments. McNeil, Capage, and Bennett address similar cultural concerns as they discuss treatment of children with disruptive behavior disorders. McNeil and colleagues point out that most of the treatment data for this disorder have been obtained from Caucasian families. She and her colleagues focus their discussion on issues relevant to treating young African American children diagnosed with behavior disorders and point out that therapists need to “incorporate variables related to ethnicity.” Emphasizing the importance of cultural issues in pediatric research and in treatment, Clay, Mordhorst, and Lehn reviewed 71 articles used to support empirically supported treatments. They found that most of the articles failed to address important issues of culture. Clay et al. call into question the external validity of empirically supported treatments because very few of the studies addressed cultural variables in any way. Yeates et al., in their longitudinal, prospective study, did address the issue of race and whether race moderates parent and family outcomes during the first year following pediatric traumatic brain injury (TBI). They concluded that race was a significant moderator of parent and family outcome. Given that the minority population within the United States will become the majority population within 20 to 30 years, we must ensure that the children we serve are educated and healthy. The NICHD (2000) reports that by the year 2030, one fourth of our nation’s student population will be Hispanic. However, current data suggest that “young Hispanic children lag behind white children in early schoolrelated skills” (p. 27) and that they have higher dropout rates (28%) in school than African American (14%) or white (8%) children. The NICHD report could easily be a call for all pediatric psychologists and pediatricians to review the way health/mental health care is delivered in hospitals and outpatient settings, with a greater focus on early intervention, consultation, and collaboration
Introduction
with agencies and organizations outside the hospital walls, and a focus on advocacy at the local, state, and national levels. Though much of the research by pediatric psychologists focuses on children with medical disorders, and the psychological impact, compliance issues, and treatment of various problems, there has been insufficient focus on family factors that influence a child’s cognitive, learning, and behavioral problems. Pediatric psychologists have broad training and experience in ways to promote positive mental health in young children. They often have access to families and young children from a variety of socioeconomic and cultural backgrounds at early ages, when preventive interventions could be most effective. By the very nature of their work, they are in a position to build collaborative “bridges” with professionals from other disciplines and work with a variety of agencies or systems that intersect with the lives of children. Given that pediatric psychologists often have access to children and families in a primary health care setting, they are a “point of entry” of these children into the mental health care arena when mental health promotion is most beneficial. For all these reasons, pediatric psychologists have an opportunity to examine their professional roles and explore new ways of service delivery, research, and advocacy that will benefit the lives of their young patients. Let us briefly examine the areas in which pediatric psychologists could play an important role.
Early Intervention and Prevention Services Although most psychologists do not consider themselves “primary care professionals,” pediatric psychologists are in the unique position to have early and periodic access to children and families across the period of development—often from the time of the child’s birth, throughout preschool years when most other professionals do not have access, and at critical transitions in the child’s development through adolescence. Whether working in hospitals or outpatient clinics, they have the opportunity to see children and families at times of well-child visits when developmental screening and anticipatory parent education can promote health and positive mental health in the child. Pediatric psychologists have an opportunity to intervene when children’s
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mental health problems are in the early stages, at a time when treatment is often more effective and can prevent more serious problems at later ages. The need for early intervention and prevention has been well documented. Knitzer (1996), in her survey of staff in early childcare programs, reported that children are entering programs with more serious and challenging behaviors and emotional needs than in the past. The NICHD (2000) report suggests that the well-being of our nation’s youths, especially in minority communities, is being threatened increasingly by unintentional injuries (accounting for over 40% of deaths in children ages 1 to 4) and intentional injuries or violence. They report that nearly 3 million children are reported as suspected victims of child abuse or neglect per year and nearly 1,000 die from such maltreatment. Statistics indicate that within minority families, the incidence of fatal child abuse is disproportionately higher than among white families. Specifically, “infant deaths due to abuse are 3.4 times greater in the African American and 3.5 times greater in the Native American population than among Whites” (NICHD, 2000, p. 23). The Institute of Medicine (1994) estimates that at least 7.5 million children and adolescents have one or more mental disorders, including attention deficit hyperactivity disorder, depression, autism, severe conduct disorder, and substance abuse and dependence. The scope of the problem is significant and speaks to the need for balancing our focus on intervention services to include increased efforts toward prevention and early intervention services. A growing body of research evidence indicates that many mental health disorders respond to primary prevention efforts and that preventive interventions are most successful when they are family-centered—responding to and building on the family’s strengths, needs, and responsibilities (Kaufmann & Dodge, 1997). Both respect for family diversity and cultural differences and integrating family culture into the service delivery are important elements of effective prevention interventions (Kaufmann & Dodge, 1997). Pediatric psychologists are trained to use a child-centered and familyfocused approach to intervention. In working with children of poverty and children from minority populations, it is important to provide programs and services that are community-based and culturally competent as well, with programs and services responding to the cultural, racial, and ethnic differ-
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ences of the population (Sroul & Friedman, 1986). Conceptualizing delivery of pediatric psychology services from a preventive and early intervention perspective allows one to incorporate the family, community, and cultural aspects of children’s mental health care into their practice.
Collaborative Relationships: Integrated Care Collaboration with others builds bridges among agencies, organizations, and communities and is essential to meet the health, social, and mental health needs of low-income, ethnic minority patients. Collaboration works and it is cost effective! When Hodges, Nesman, and Hernandez (1998) wrote their volume on collaboration in the Systems of Care series, they stated that “when child-serving agencies focus on the needs of children and families that the agencies share more similarities than differences. Not only are relationships improved among childserving agencies, but the services they offer are more individualized, less restrictive, and anchored in their community” (p. xi). There are several ways in which pediatric psychologists and hospitals might collaborate with other entities to promote the well-being of children and families. • Pediatric psychologists and hospitals must collaborate by necessity with the agencies handling Medicaid and the Children’s Health Insurance Program (CHIP) because of the large numbers of children (11.9 million) currently uninsured in America (Children’s Defense Fund, 2000). • In every community there is a Head Start or Early Head Start program mandated to ensure that children have a medical home and mental health consultation. While the five billion dollar budget for Head Start does not pay for health coverage, there are monies for mental health consultation through contracts with local programs, unless these programs have hired their own mental health staff. Pediatric psychologists who collaborate with this population can help to prevent and reduce behavioral and other mental health disorders in the young child. • To reach minority groups, collaboration with minority programs, clinics, and centers is important, not only to increase the census at hospitals but also to provide much needed services to these
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populations, and with the cooperation of these programs, to generate new knowledge through research. For example, Children’s Hospital of Oklahoma provides pediatric services on-site at the large Latino Center in Oklahoma City, and the Child Study Center provided on-site developmental and mental health consultation to the children’s program. The early intervention services provided could potentially have long-term implications by prevention of more serious health and mental health problems among this low-income minority group. Or, as Flowers, Lanclos, and Kelley show in their article, they recruited a sample of 182 African American children and their parents from schools and clinics for the purpose of validating a screening instrument for exposure to violence in this population. Thus, collaborating with different organizations yielded an instrument that might be used to assess the role of violence exposure on the behavioral and emotional problems in African American children. • Collaboration with schools is critical because many low-income or ethnic minority children seen in clinics present with learning or behavioral problems. Pediatric psychologists are often on the cutting edge of knowledge and expertise with regard to treating behavioral problems and can collaborate with school personnel to help reduce behavioral disorders, thereby enhancing the child’s development and successful school experience. Tucker has developed an effective universityschool-community research-based model to improve academic achievement and adoptive skills in a low-income minority community described in this issue. Children in her program had better grades than control children when assessed at 2year and 4-year follow-up periods, and there were decreases in assessed behavior problems. • Collaboration with families is imperative. Too often pediatricians and psychologists make excellent recommendations for the welfare of the child with little knowledge of the family’s circumstances or ability to carry out these recommendations. Also, recommended services are often fragmented and may not be “family friendly,” or the family’s resources do not include reliable transportation or the confidence and motivation to carry out suggestions. After making a home visit to one of my patients—a mother and her children—it was clear how difficult it would be for her to follow my recommendations regarding “appropriate” play and
Introduction
opportunities for activity for her children. Her small apartment, located in a high-crime, highviolence housing complex, made it unsafe for any of the family to be outdoors. • This leads to the sixth collaboration—with communities and neighborhoods. Children need not only a healthy start in life, as the Children’s Defense Fund (2000) report states, but also a safe start. Over 80,000 American children have been killed by guns since 1979—a greater casualty rate than we suffered in battle casualties in the Vietnam War. American children under 15 are 12 times more likely to die from guns than children in 25 other industrialized nations combined. A child is reported abused or neglected every 12 seconds. Children are exposed to relentless glorification of violence on movies, television, and Internet screens. (p. xix) In every major city pockets of communities or neighborhoods are unsafe for children and their families. Many of the low-income or ethnic minority patients seen in pediatric clinics reside in these neighborhoods. Can pediatric psychologists do anything to change the dysfunctional and unsafe environment within these communities? In Oklahoma City, the Latino Center is located in a rundown, low-income area of the city. The director of the center collaborated with business leaders, the police, school personnel, and her own clients to clean up the area and make it safe for families and children. Violence has been reduced and a “zero tolerance” for criminal activity has emerged. Housing projects can be made safer and on-site services could be provided with the right motivation, energy, and spirit of collaboration. Indeed, outreach pediatric and psychological services could be provided on-site within housing projects. • Collaboration with state and local agencies is important to ensure that low income and ethnic minority patients receive all the services they need. Trust among agencies must be developed, and sharing of resources may be necessary. Someone has to start the process!
Advocacy Advocacy takes many forms. First, the data that pediatric psychologists can collect within the outpa-
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tient and inpatient units of hospitals, depending upon questions asked, can be valuable for the hospital staff as they advocate for more monies and services to poor or ethnic minority patients and their families. Not only data about families and children but also location of their residence within the community at large may be of use in establishing outreach clinics or other services. As an example, data about teen pregnancy, low birthweight, prenatal care, support systems for the pregnant teen are important areas of study—especially since the U.S. teen birth rate is 14 times the rate in Japan and twice as high as in Canada or Australia (Child Trends, 2001). Teen birthrates are substantially higher for African Americans, American Indians, and Hispanics. This makes the babies of teen mothers at higher risk for all kinds of developmental problems. Thus, data can help hospitals advocate for more preventive services and for a statewide effort to reduce the incidence of teen pregnancy. Data on uninsured children, homeless children and families, child abuse and neglect, selected medical disorders and their impact on children (especially if community- or school-based services are unable to meet the needs of the children and families), are very valuable for hospital administration, mayors, city council members, and local legislators. Thus, pediatric psychologists can be advocates for their patients through relevant and informative research. Second, it may be necessary not only to collaborate with but also to advocate for patients needing special services within the school setting. Discrimination based on race still occurs and a conference between the pediatric psychologist and teacher may facilitate the provision of resources and promote a more positive attitude toward the child. Pediatric psychologists could also advocate for ethnic minority or poor children by serving as a member of local or state committees and parent organizations. This not only provides advocacy for the populations they serve but also provides positive representation for the hospitals in which they are employed. Third, we can advocate within our own departments and agencies for more training on cultural issues and seek to tailor psychological treatments to specific cultural contexts. In summary, this special issue of JPP, focusing on the health/mental health disparities of low-income and ethnic minority children, serves to heighten awareness of the special opportunities pediatric psychologists have in early intervention and preven-
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tion, collaboration, and advocacy for this population. It is important to incorporate lessons on cultural sensitivity, collaboration, and advocacy not only in our clinical practice but also within all levels of psychological training, so that future psychologists will enter the professional arena with a mindset oriented toward these issues.
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Acknowledgments Special appreciation is expressed to John Chaney, PhD, for his assistance with this issue and to Jan L. Culbertson, PhD, for her helpful comments on this article.
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National Institute of Child Health and Human Development. (2000). Health disparities: Bridging the gap. Rockville, MD: National Institute of Child Health and Human Development. Stroul, B. A., & Friedman, R. M. (1986). A system of care for children and youth with severe emotional disturbances (Rev. ed.). Washington, DC: Georgetown University Child Development Center, National Assistance Center for Children’s Mental Health. U.S. Department of Health & Human Services. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author. U.S. Department of Health & Human Services. (2001). Mental health: Culture, race, and ethnicity. A supplement to Mental Health: Report of the Surgeon General. Rockville, MD: Author. U.S. Public Health Service. (2002). Report of the Surgeon General’s Conference on Children’s Mental Health: A national action agenda. Washington, DC: Author. Willis, D. J. (2000a). American Indians: The forgotten race. Clinical Psychology of Ethnic Minorities, 8(3), 1–2. Willis, D. J. (2000b). Children’s unmet health and mental health needs. Clinical Psychology of Ethnic Minorities, 8(1), 1–2.
