While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Many of the experiences, attitudes, and beliefs of immigrants and refugees differ from those of native-born Americans. Understanding these differences was the key to developing culturally competent approaches to mental health services for immigrant and refugee students in Brooklyn, N.Y., Chicago, and Los Angeles during Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth. The Robert Wood Johnson Foundation national program brought school-connected mental health and usually also supportive services such as case management to immigrants and refugees at 15 sites in eight states from 2007 until 2010.
The Bridges project in Brooklyn, and the 3 R's Project at Norwood Street Elementary School in Los Angeles (one of two Caring Across Communities projects in that city), worked with immigrants: Afro-Caribbean immigrants in Brooklyn and Central American immigrants in Los Angeles. The Chicago project worked mostly with refugees from Africa (Burundi, Liberia, and Somalia), Burma, and Iraq.
Helping Children Do Well in School. Whichever countries they come from, immigrants and refugees share a deep respect for the U.S. school system. "Parents come here as a result of wanting their kids to have access to better education. Their hope is that education will transform their kids' lives," said Kristen S. Huffman-Gottschling, MSW, LCSW, director of the Horizons Clinic at World Relief-Chicago, a refugee resettlement agency, and project director for Caring Across Communities in that city.
Parents who are immigrants and refugees often show respect by giving teachers and the school significant authority over their children, and they keep their distance. However, their expectations differ from those of teachers and schools in America.
For example, when a child misbehaves in a U.S. school, the teacher calls the parents. In Afro-Caribbean culture, teachers handle discipline. The Bridges program brought teachers and parents together one-on-one at the beginning of the school year, before any issues came up, so they could get to know each other and talk about their expectations. This helped build trust and made parents feel more comfortable working with teachers to resolve problems later in the school year.
In Chicago, when a conflict between a teacher and a parent around a child's behavior occurred, usually because of a cultural misunderstanding, project staff would observe the child in the classroom and make recommendations to the teacher, family, and student.
All three programs trained teachers in cultural competence, and had staff available to work with them one-on-one. Training in Chicago, for example, ranged from explaining the refugee process to showing teachers how to build rapport with immigrant and refugee families and communities.
In Los Angeles, the 3 R's Project conducted in-service training for Norwood’s teachers and staff on prominent mental health issues among immigrants. Its on-campus Walk-in Center provided easy access for the families seeking information and help. Additionally, teachers and administrators could stop by a Walk-in Center to get advice and information on working with immigrant and refugee families from the 3 R's family advocate or therapist. The Walk-in Clinic was the site for 3R’s services—individual, family, and group therapy.
Combating Stigma Against Mental Health Problems. Afro-Caribbean people, people from Mexico, and many other immigrant and refugee groups believe that people who have mental health problems are "crazy." Reframing mental health services as a way to help children do well in school enabled Caring Across Communities programs to combat this stigma.
"We were talking about academic success and emotional skills; we really reframed the services," said Esther Calzada, assistant professor of child and adolescent psychiatry at New York University, and head of the Caring Across Communities project in Brooklyn.
In Los Angeles, the 3 R's Project addressed the issue of stigma in several ways. At the start of the project, a handful of parents were chosen to participate as advisers. They named their group "Parent Supporters." They provided advice and gave direction on activities, the messages to parents, and the best means to send the messages. They also gave direct help, for example, distributing flyers, and talking with family and other parents about the 3R's informally and at school meetings. In their community, this word-of-mouth promotion carried much weight and was invaluable in countering the stigma of mental health and fear of accessing services.
Also, the 3 R's therapist led parent education classes on emotional and behavioral issues. These classes reached many parents who then saw that counseling services could aid their children and themselves with real-life issues. "They could see that mental health services weren't just for people who were crazy, that regular families had problems and mental health services could help them," said Eric Inouye, LCSW, community access coordinator at the Los Angeles Child Guidance Clinic, and project director for Caring Across Communities at Norwood Street Elementary School.
Partnering with Parents. All three projects also partnered with parents through parent groups, classes, and meetings. Bridges had a 14-week parenting program that began with parents teaching project staff about Afro-Caribbean culture. "We explicitly asked families to educate us about their culture, and how it relates to parenting and child-rearing, and managing children's behavior and promoting their skills," said Caldoza.
Project staff then modified parenting strategies so that they would work in Afro-Caribbean culture. For example, a common U.S. parenting strategy is to ignore certain behaviors of young children that are not dangerous, such as whining or throwing a tantrum. In Afro-Caribbean culture, parents believe that it is shameful if a child misbehaves in public. So staff suggested ignoring these behaviors at home and using a different strategy in public, such as taking away something the child wants (for example, a certain toy) if the behavior continues.
Project staff in Chicago ran a parent group that covered everything from nutrition to how to advocate for children in the school system. Staff also met with parents to help them with challenges such as understanding the school system, and served as a liaison between the parents and teachers.
The Norwood school 3 R's Project's parent supporters group advised, directed, and provided direct help to the project. Also, they helped project staff develop culturally competent services.
Employing Cultural Brokers. To help build relationships with students and families, the projects employed cultural brokers—staff who were from the immigrant and refugee communities they were working with, and could communicate in their language. Bridges, for example, had Afro-Caribbean representatives from social service agencies and faith-based organizations work side by side with psychologists and social workers from New York University. The community representatives included a social worker and a teacher, both from the faith-based organization New Hope.
For the 3 R's Project, The Los Angeles Child Guidance Clinic hired bilingual, bicultural staff. Thus, services were provided in the families' native language by staff who could empathize with them. Additionally, as the parent supporters spoke Spanish, project meetings were conducted in Spanish. "This gave the message to our clients and parent supporters that they were valued. It was empowering for them," said Inouye.
Celebrating Culture. The Caring Across Communities sites also found ways to help immigrants and refugees celebrate their culture. In Los Angeles, the therapist developed a cinema therapy group and a parent education class on the immigration experience, "My Journey." She used Spanish-language movies that depicted one of the three stages of immigration: leaving, crossing, and adjusting. She showed the film (or an excerpt) and then led a discussion of what the film had shown and the parents' experiences. Through these therapeutic experiences, parents could see themselves and their children as a mix of cultures and then relate better to their children.
In Brooklyn, parents worked on a culture book that covered Afro-Caribbean music, food, holidays, a family tree, and more. They shared this with each other and their children. Some parents also presented their culture books in the classroom.
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