BHIPP Bulletin
Volume 7, Issue 9
March 2022
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Culturally Responsive, Trauma-Informed Practices for Pediatric Primary Care Providers |
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This month's BHIPP Bulletin is a contribution from Dr. Tiffany Beason, PhD. Dr. Beason is a licensed clinical and community psychologist at the National Center for School Mental Health and an Assistant Professor in the Division of Child and Adolescent Psychiatry at the University of Maryland School of Medicine. Dr. Beason has served as a school mental health clinician in the Baltimore City Public School System for several years. Dr. Beason serves as the director of Cultural Responsiveness, Anti-Racism and Equity within the National Center for Safe Supportive Schools. Dr. Beason is also a co-developer of a national curriculum for educators to promote culturally responsive and equitable mental health support in classrooms. She presented this month's BHIPP Resilience Break webinar, watch the recording here.
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Culturally responsive care involves intentionally honoring and integrating the child and family’s cultural- and identity- based values, beliefs, strengths, needs and expectations into healthcare services. This can involve seeking to understand youth and family health beliefs and expectations of care, understanding and addressing linguistic needs, and honoring cultural-based family dynamics that impact decisions about treatment. Culturally responsive practices by providers are important given their impacts on increased patient satisfaction, adherence to treatment and better health outcomes.1 Furthermore, cultural responsiveness is an aspect of culturally competent care, which is essential to addressing health care disparities and provision of high-quality healthcare services for all.2
Culturally responsive practices that are trauma-informed to the extent that they involve providers actively embodying cultural humility. Cultural humility is defined as the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity…”.3
Cultural humility is a lifelong commitment to self-evaluation and critique, to learning about diverse cultures, and working to limit power imbalances and dismantle systems of oppression.3 Racism and other forms of oppression (i.e., heterosexism, cisnormativity, ableism, etc.) are often experienced as traumatic to individuals and communities impacted by them. Thus, actively working to understand and address the impacts of racism and other forms of social injustice (oppression) on patients aligns with a trauma-informed approach.
This newsletter summarizes some culturally responsive, trauma-informed practices for pediatric and behavioral health providers. It also offers resources to support providers with implementing these strategies.
Manage provider implicit biases.
Healthcare providers have an ethical duty to, at minimum, do no harm. However, each individual possesses implicit biases (preferences for or prejudices against different groups) that can translate to individual providers engaging in discriminatory behaviors and micro-aggressive acts that are harmful to patients. Providers are encouraged to engage in critical self-reflection about how common implicit biases (including stereotypes about specific groups) may impact their clinical practices, i.e., patient rapport building strategies, clinical case conceptualizations, language used to describe patients, etc., their relationships with patients and the quality of care provided to patients across cultural backgrounds. Providers can utilize clinical supervision, peer consultation, independent study, and continuing education to effectively manage and address their implicit biases to limit harmful practices and optimize quality of care to all patients. The Harvard Implicit Association Test is a resource individuals can use to increase their understanding of their own implicit biases. Providers should also look to their healthcare system, agency or institution to request and participate in trainings related to fostering cultural humility and addressing implicit biases. The University of Maryland School of Medicine offers an “Everyday Bias for Healthcare Professionals” course to support healthcare workers with understanding and managing their biases to promote high quality patient care for all.
Understand that racism and other forms of oppression impact individuals and communities at multiple levels.
Racism and other forms of oppression are social determinants of health5 that impact patient physical and mental health and well-being, by operating at multiple levels. Dr. Camara Jones described a framework of racism operating at three levels4, which are described below.
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Institutionalized racism involves differential access to the goods, services, and opportunities of society by race.
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Personally-mediated racism is loosely defined as prejudice and discrimination, or acts that happen person-to-person so to speak.
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Internalized racism involves Black, Indigenous and People of Color (BIPOC) accepting negative societal messages about their own abilities and intrinsic worth.
Of note, other forms of oppression, including sexism, for instance, operate at similar levels. It is important that providers understand social oppression operates at multiple levels, each of which impact the lived experiences of individuals and communities that are marginalized. Dr. Jones facilitated a helpful TEDTalk where she creatively illustrates how racism works at multiple levels, using allegories as a method of teaching this framework.
Broaden your understanding of trauma to include historical trauma and discrimination.
Trauma is often thought of as being caused by discrete incidences that involve the actual or possible threat of death, violence, or serious injury. However, traumatization does not solely occur from the experience of discrete incidents. In fact, people from marginalized communities experience a society that perpetuates historical trauma, which is loosely defined by the cumulative harm to a group caused by an historical event (such as genocide, violent colonization, slavery) and the related on-going oppression via discrimination, as one example. Historical trauma can have impacts across generations, and is associated with lower self-esteem, lack of self-efficacy, lack of identity, insecure attachment, and poor coping skills.6
Engage in trauma-informed screening and assessment that explores the impacts of racism and discrimination on patients.
Providers should be sure to utilize best practices for trauma-informed screening and assessment in their process of screening for trauma in order to avoid re-traumatization. The National Child Traumatic Stress Network published a guide for conducting trauma-informed mental health assessment with practical tips to foster trauma-informed assessment and screening processes that are sensitive and developmentally appropriate.
Screen for and support families in fostering Positive Childhood Experiences.
In the process of screening for trauma, also screen for Positive Childhood Experiences (PCEs: feeling able to talk to your family about feelings; feeling your family stood by you during difficult times; enjoying participating in community traditions; feeling a sense of belonging in high school; feeling supported by friends; having at least two non-parent adults who took genuine interest in you; and feeling safe and protected by an adult in your home), which can mitigate the negative impact of adverse childhood experiences (ACEs).7 Assessing for protective factors, like PCEs, is a helpful way to engage all patients, especially those from marginalized communities that are often overly pathologized or problematized. The Center for Disease Control published a brief guide about Creating Positive Childhood Experiences that pediatric and behavioral health providers can use in their process of supporting families with fostering positive childhood experiences.
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Use a strengths-based approach to care.
Within many cultures, there is a stigma associated with mental health difficulties, and a parent may justifiably become defensive if their child is being labeled by their problems and not appreciated for their strengths. A strengths-based approach can reduce stigma and a family’s fears of their child being negatively labeled. It involves asking youth and families “What is right with you?”, leading with what the child does well, presenting challenges as areas of growth, describing mental health services as “additional supports” to help the child or family meet their goals, and then focusing intentionally on promoting positive views of self, healthy relationships, and adaptive skill sets.
Promote cultural-based strengths.
Pediatric and behavioral health care providers can promote cultural-based strengths, or skills and strategies that youth and families use to thrive and be well in the face of oppression. Many Black Indigenous and People of Color families prepare their children for racism and other forms of oppression by teaching youth about these issues and various ways to resist injustice. Some of the more common strategies include seeking out safe spaces and support from group members or allies, demonstrating group pride through participating in cultural celebrations, acknowledging and celebrating community-based strengths, displaying symbols of cultural or identity-based pride, and using advocacy skills to speak out against injustice.
Providers who work in community-based and school settings, can help to foster service and educational environments that support young people with leveraging their cultural-based strengths to promote positive mental health and well-being.
Ask about youth and family culture and identity.
Embrace cultural differences and assets by inviting youth and families to share about their cultural backgrounds and identities. In the process of learning about patient cultures, backgrounds, beliefs and values providers can learn important information about health beliefs and practices that can inform the clinician’s approach to patient education as well as problem-solving barriers related to treatment adherence. The Fraser Health Authority published a helpful resource called “Questions you can ask to understand the beliefs, values and needs of your patient/client/ resident” that offers some sample questions providers can use to learn about patient culture and health related beliefs, practices and values. The Washington State Department of Children, Youth and Families published a resource called Culturally Responsive Assessment Questions for CBT+ that offers a list of questions that providers can use to learn about youth and family cultures and backgrounds.
Partner with families to overcome barriers to accessing mental health services.
Youth and families from groups that are marginalized experience significant barriers to accessing mental health services. Some people, including those within the LGBTQ+ and African American communities, lack trust in mental health services due to the history of unethical, homophobic and racist practices in mental health care. Also, as a result of mental health stigma, some may be reluctant to seek help. Additionally, people from different religious and spiritual backgrounds may prefer to receive supports through their religious community. Below are some strategies to support families with overcoming barriers to accessing treatment:
- Validate the youth and family's feelings, especially concerns or worries about stigma and/or being treated unethically by providers.
- Inform families that mental health problems in children are common and quality mental health support and services are helpful.
- Acknowledge the history of unethical practices, and educate families on the fact that harmful practices are banned among professional academies and agencies. Also, many therapists have specialized training in providing affirming and effective care to people from diverse communities.
- Encourage families to openly express their needs to providers and ask providers questions about their training to ensure the therapist is a good fit for them.
- Also consider referring families to providers or organizations known to the community if you do not have availability to add them to your caseload or the family prefers services outside of school.
References:
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Lukoschek P. African Americans’ beliefs and attitudes regarding hypertension and its treatment: A qualitative study. Journal of Health Care for the Poor and Underserved. 2003;14(4):566–587. https://doi.org/10.1353/hpu.2010.0690
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Betancourt, J. R., Corbett, J., & Bondaryk, M. R. (2014). Addressing disparities and achieving equity: cultural competence, ethics, and health-care transformation. Chest, 145(1), 143–148. https://doi.org/10.1378/chest.13-0634
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Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. https://doi.org/10.1353/hpu.2010.0233
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Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health, 90(8), 1212–1215. 10936998.pdf (nih.gov)
- https://health.gov/healthypeople/objectives-and-data/social-determinants-health
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Heart, M. Y. H. B., Chase, J., Elkins, J., & Altschul, D. B. (2011). Historical trauma among indigenous peoples of the Americas: Concepts, research, and clinical considerations. Journal of Psychoactive Drugs, 43(4), 282–290. https://doi.org/10.1080/02791072.2011.628913
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Bethell, C., Jones, J., Gombojav, N., Linkenbach, J., & Sege, R. (2019). Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels. JAMA Pediatrics, 173(11), e193007. https://pubmed.ncbi.nlm.nih.gov/31498386/
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As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at
855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.
We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.
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Attention Maryland PCPs! Join Optum for a FREE training on the updated Autism Spectrum Disorder and Modified Checklist for Autism in Toddlers - Revised (M-CHAT-R). This is a two part training on April 1st and April 8th. Learn more and register here: https://bit.ly/3upm4rZ
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BHIPP in Your Neighborhood |
- April 22, 2022 12:30-1:30pm
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BHIPP Resilience Break: Autism Spectrum Disorder in Primary Care: Supporting Children and Families presented by Anna Maria Wilms Floet, MD
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Register here!
- May 1, 2022
- MedChi, the Maryland State Medical Society Conference
- Come visit our exhibit booth!
- May 6, 2022 12:30-2:00pm
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BHIPP and Maryland Addiction Consultation Service (MACS) webinar in honor of Children's Mental Health Matters Week: Approaches to Co-Occurring Substance Use and Psychiatric Disorders in Youth presented by Marc Fishman, MD
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Register here!
- May 23, 2022 12:30-1:30pm
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BHIPP Resilience Break: Avoiding Provider Burnout presented by Mary Ann Booth, MD
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Register here!
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Interested in organizing a (virtual) training event? Need more information? Message our team!
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BHIPP Holiday Closures Calendar |
Please note that the telephone consultation line will be closed on the following upcoming holiday(s):
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BHIPP is supported by funding from the Maryland Department of Health, Behavioral Health Administration and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins University School of Medicine, Salisbury University and Morgan State University.
BHIPP and this newsletter are also supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $433,296 with approximately 20% financed by non-governmental sources. The contents of this newsletter are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. For more information, visit www.hrsa.gov.
Copyright © 2021 Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP), All rights reserved.
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