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Book Reviews

Culturally Diverse Children and Adolescents: Assessment, Diagnosis and Treatment.

Apfel, Roberta J. M.D., M.P.H.

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The Journal of Nervous and Mental Disease: January 2002 - Volume 190 - Issue 1 - p 57-58
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Culturally Diverse Children and Adolescents: Assessment, Diagnosis and Treatment. Canino, Ian A., and Spurlock, Jeanne. New York: Guilford Press, 2000. xii + 228 pp. $29.00.

This is an updated version of a landmark book first published in 1994. It is filled with practical information that will be useful for mental health professionals, educators, primary caregivers, and others working with children and adolescents. Preserved is the basic focus on the stress of prejudice and discrimination as experienced by the African American, Asian American, Latino, and Native American youth. Added is a wealth of research findings, diagnostic techniques, and model programs to illustrate the message that understanding cultural diversity is crucial in work with children and adolescents. With numerous clinical vignettes, the universality of this message becomes compellingly clear. The authors, psychiatrists the late Jeanne Spurlock and Ian Canino, and the psychologist Carmen Rodriguez, have vast experience that led them to conclude: “health-seeking behaviors vary across culture and socioeconomic level, the sociocultural context affects mental health and symptomatic behaviors, and it is difficult to differentiate between behavior that is unique to a particular culture and behavior that is specific to socioeconomic level” (p. 3).

The book comes at a time when cultural competence is more appreciated by institutions and in public policy. However, this is also a time when there is more diversity in the population and more economic hardship in medical care. Diversity is cultural, economic, and social, e.g., involving the child in a home with two parents of the same gender, to which the precepts of this book also will apply. Here is a guide to clinical care by which we can truly value our nation’s children and youth, the unique person each of them is, and the diversity of their life situations.

Culturally Diverse Children and Adolescents is organized into three parts: I) a perspective for the clinician, II) the diagnostic challenge, and III) the treatment of culturally diverse children. An unusual last chapter speaks to the need for clinicians to broaden their involvement and to use their training and power to serve as advocates for young people. The valuable bibliography is another resource the book provides for its readers. The term “culturally diverse groups” is cumbersome but far more accurate and descriptive than “minority.” The reader is repeatedly advised to listen to the patient, e.g., to how they identify themselves, rather than to make assumptions.

Part I is an excellent review of the concept of ethnicity, of identity, socialization, and language; the social stressors of prejudice, poverty, migration and acculturation, and learning in school are considered thoroughly and thoughtfully in what could be required reading for every trainee planning to work with children in this country. It reviews protective factors as well as risk factors and demonstrates the value of school-based intervention. Whenever schools, or any intervention, raise the self-esteem of the child, there is a better behavioral and emotional outcome.

The call for the “formal introduction of a consideration of culture in psychiatric training programs and in the training of other mental health professionals, thus acknowledging that prejudicial attitudes and stereotypes about members of other cultures tend to dull the diagnostic and treatment skills of clinicians (p. 192)” is placed too late in the volume. I found myself thinking throughout about the education of medical students and graduate students, e.g., who will teach this cultural awareness and how? The inclusion increasingly of culturally diverse trainees is an asset we can use in training programs as we shift away from homogenizing the experience into a single professional cultural identity. This book will increase our awareness and ability to use the diversity at hand to inform one another.

Part II on history-taking is a fine guide for work with adults as well as with youth. Indeed, much of the history is gathered from parents (as well as from grandparents and community elders) and from teachers. Considerations of the family constellation and of the belief systems texture and deepen the more familiar history of intrapsychic and interpersonal factors. The authors are very sophisticated about eliciting psychodynamic meaning for an individual child within the context of his/her world. They provide an ideal for comprehensively getting to know the individual child, an ideal that may not currently be practical but nevertheless provides a useful standard.

Rodriguez’ masterful overview, chapter 3 “Culturally Sensitive Psychological Assessment” presents a great deal of new data about techniques for evaluating children. She reiterates the necessity for evaluators to be “self-reflective and sensitive to their own cultural norms and practices” while indicating that “no clinician can have expertise in psychological instruments appropriate for every group within a dynamic multicultural society or knowledge of every culture” (p. 85). We are reminded of the pitfalls of standardized testing, now regaining popularity in some educational circles, and of Howard Gardner’s definition of intelligence as “the ability to solve problems or to produce products valuable to a specific culture” (p. 97).

Diagnostic categories follow the DSM-IV closely, axis by axis, showing how that manual can be useful in work with culturally diverse children while reminding us of the caveat within DSM-IV itself: “A clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual’s culture” (p. 104). That said, this book then provides information about a huge range of presenting problems: posttraumatic stress disorder, incarceration, substance abuse, eating disorders, gender identity disorders, general medical conditions, etc. The therapeutic interventions section is the thinnest and somewhat redundant only because such an excellent thorough job has been done anticipating therapy with complete evaluation. The use of stories about children and folk tales with children makes the impact of this book very immediate. The direct quotations from the writing of children are most compelling. The complexity of the work with youth is never underestimated, and the rewards are made apparent in this text.

In my own work with children of war, I have seen how adults consistently tend to underestimate trauma to children who they want to believe they have protected. This book is an education in itself to adults who want to know more about how children are making meaning of their lives. It is written in an inviting and informative way that intrigued this reader and will, it is hoped, make many more readers/clinicians less defensive and more effective in their work with culturally diverse children and adolescents.

Roberta J. Apfel, M.D., M.P.H.

Associate Clinical Professor of Psychiatry, Harvard Medical School

© 2002 Lippincott Williams & Wilkins, Inc.