DOCUMENT RESUME

ED 332 461 EC 300 324

AUTHOR Roberts, Richard N.; And OthersTITLE Developing Culturally Competent Programs for Families

of Children with Special Needs. 2nd Edition.INSTITUTION Georgetown Univ. Child Development Center,

Washington, DC.PUB DATE Sep 90NOTE 43p.; For a related document, see EC 300 325.PUB TYPE Guides - Non-Classroom Use (055) -- Reports -

Descriptive (141)

EDRS PRICE MF01/PCO2 Plus Postage.DESCRIPTORS Community Programs; *Cultural Awareness; Cultural

Differences; *Delivery Systems; *Disabilities; EarlyChildhood Education; Ethnic Groups; FamilyInvolvement; *Family Programs; OrganizationalDevelopment; Program Descriptions; ProgramDevelopment; State Programs

ABSTRACTThis monograph provides a framework for programs,

states, and organizations to think about the issues in developingculturally competent programs for families of children with specialneeds, and offers a variety of examples from programs across thecountry that are providing exemplary services. The monograph isdesigned to help program makers compare their efforts with others, toprovide options for planning additional services or altering servicesin existing programs, or to develop new programs. Monograph sectionscover the following topics: (1) general issues in developingculturally competent programs as they relate to community-basedfamily-centered care; (2) specific issues in policy and practice,such as assessment, outreach, family involvement, staffing, use oftranslators, client load, professional-paraprofessional partaerships,and training and support; and (3) descriptions of programs funded bythe Bureau of Maternal and Child Health that serve families inseveral different types of settings. (15 references) (JDD)

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* Reproductions supplied by EDRS are the best that can be made *

* from the original document. *

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U.S. DEPARTMENT OF EDUCATIONOffice of Educahonal Research and ImprovementEOU#TIONAL RESOURCES INFORMATION

CENTER (ERIC)dloChitt document has been reproducsi asreceived horn the person or organization

originating itO Minor changes have been ma ie lo improve

reproduction quality

Points of view or opinions slated in this docu-ment do nol necesamily represent officialOERI position or policy.

"PERMISSION TO REPRODUCE THISMATERIAL HAS BEEN GRANTED BY

TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)."

DEVELOPING CULTURALLY COMPETENT PROGRAMS

FOR FAMILIES OF CHILDREN WITH SPECIAL

NEEDS

2nd Edition

Prepared by

Georgetown University Child Development Center3800 Reservoir Road NWWashington,DC 20007

Maternal and Child Health BureauSeptember,1990

BEST COPY AVAILABLE

DEVELOPING CULTURALLY COMPETENTPROGRAMS FOR FAMILIES OF CHILDREN

WITH SPECIAL NEEDS

2nd Edition

Richard N. Roberts

In collaboration with:

Gina Barclay.McLauglillnJames ClevelandWanda Colston

Rand! MalachLaurie Mulvey

Gloria RodriguezTrish Thomas

Dorothy Yonemitsu

!Prepared byGeorgetown University Child Development Center

3800 Reservar Road NWWashington, DC 20007

iaternal and Child Health BureauSeptember, 1990

3

ACKNOWLEDGEMENTS

This monograph and workbook are the result of the combined efforts of many people. In par-ticular, program representatives from each of the programs listed below gave freely of their timeand ideas to help make this series a reality: Randi Malach, Norm Segal, and Trish Thomas ofthe EPICS Project; Jim Cleveland, Dorothy Yonemitsu, and the entire staff of the SEADD Project;Gina Barclay-McLaughlin and the staff of the Beethoven Project; Wanda Colston of the Trans-generational Project; Gloria Rodriguez of the Avance Project; and Laurie Mulvey of Families Fac-ing the Future. Pearl Rosser, Aaron Favors, and Phyllis Magrab served as advisors to this effort.The staff and families of the Prekindergarten Program of Kamehameha Schools helped shapethat program into a model program and served as the foundation for many of the ideas pre-sented in this monograph and accompanying workbook. Special thanks to Phyllis Magrab andthe staff of the Georgetown University for their assistance, and to Debbie Risk and Kelleen Ham-bly for their assistance in preparing the manuscript foir publication. The staff of the Division ofServices for Children with Special Health Needs (MCHB) have been particularly helpful. DianaDenboba deserves special praise for her commitment to ensuring that culturally competent ser-vices are provided to children with special health needs across the country.

The Minority Initiative Resource Committee (MIRC) from the Child and Adolescent Service Sys-tem Program (CASSP) Technical Assistance Center was responsible for the publication of anindependent monograph, Towards a Culturally Competent System of Care: A Mono-graph on Effective Services for Minority Children Who are Severely EmotionallyDisturbed, prepared by T. Cross, B. Bazron, K. Dennis, and M. Isaacs. The work of the MIRC increating a conceptual framework through which cultural competence can be viewed within allallied health professions is much appreciated. We would also like to thank MIRC for reviewingthis monograph and workbook.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS

INTRODUCTION .1

The Community Base of Culturally Competent Services 2

What Makes a Program Culturally Competent? 4

Types of Programs Providing Services. 8

Issues in Policy and Practice 1 1

Policy 1 1

Practice 1 2

Specific Issues in Practice 1 3

Assessment 1 4

Outreach 1 5

Family Involvement 1 6

Staffing 1 6

Use of Translators 1 7

Client Load 1 8

Professional-Paraprofessional Partnershipsin Culturally Competent Programs 1 8

Training and Support 1 9

SUMMARY 1 9

Programs in Action 1 9

Informal Survey 20

PROGRAM DESCRIPTIONS 21

Kamehameha Schools Prekindergarten Education Program 2 1

Center for Successful Child Development 24(The Beethoven Project)

Families Facing the Future 2 6

Southeast Asian Developmental Disabilities Prevention Project 2 8

Transg ene ratio nal Project 30EPICS 30Avance 3 4

REFERENCES 3 8

FOOTNOTES 38

INTRODUCTION

[IIhis monograph and its accompanyingworkbook is designed to help programs,states, and organizations improve their abilityto provide culturally competent services tofamilies. The monograph provides a frame-work for you to think about the issues in devel-oping culturally competent programs as wellas a variety of examples from programs acrossthe country that are providing exemplary ser-vices at this point. The accompanying work-book provides an opportunity for individualsand groups involved in program planning toexamine their own efforts against a set ofquestions and activities which are drawn fromthe issues in the monograph. The two publi-cations are designed to be used concurrentlyas programs and states work together withtheir communities to provide services to fami-lies in the most culturally competent manner.Both the monograph and the workbook repre-sent our best efforts to understand the issuesrelated to cultural competence. As such, theyare open to continued input and developmentas we learn from programs and groups strivingto effect service delivery systems. The goal ofthis effort is to make them more responsiveand competent in their interactions with fami-lies of children with special health needsacross the cultural spectrum of the UnitedStates.

Several different audiences may find thisseries useful. If your program is already pro-viding culturally competent services to familiesand children, you may wish to use the mono-graph to find out what other programs aredoing across the country and to compare yourefforts with others. New contacts and ideasmay come from such an exercise. If your pro-

gram is interested in expanding services toreach groups currently not being served, thematerial in this book can provide options foryou to consider in planning additional servicesor alter services currently being provided tofamilies. If your group is interested in startingnew programs to meet a particular need withinyour community, this monograph provides theopportunity to learn from the experience ofothers. Again, contact can be made and ideaslearned from some of the hard roads othershave taken.

If you are part of your state's interagencycoordinating council for P.L. 99-457, you havethe opportunity to insure that services relevantto all cultural groups within your state are pro-vided as you develop new initiatives for youngchildren and their families. The planning andimplementation of all components of this laware affected when the issues involved in multi-cultural programs are addressed. Thisincludes the definition of handicapping condi-tions, outreach efforts in Project Find, servicedelivery models, assessment procedures, bothpreservice and inservice training efforts, par-ent participation, and how the IndividualizedFamily Service Plan is developed. Membersof Interagency Coordinating Councils andother state-wide planning efforts will find aseparate study guide for their use in the work-book.

This monograph is organized into severalsections. First, general issues in developingculturally competent programs will be dis-cussed as they relate to community-basedfamily-centered care. Then, specific issues inpolicy and practice are discussed ;r1 the con-text of culturally competent services. Next,programs that have been developed to specifi-cally serve families in several different types ofsettings are described within the context ofcommunity-based, family-centered and cultu-rally competent care for children with specialhealth needs.

1

0

The Community Base of CultvrallyCompetent Services

The concepts which underlie the principlesof culturally competent health care are notnew. However, it has become a more compel-ling and relevant issue as America continuesto become a more pluralistic society andhealth care systems work to become more uni-versal and effective in their coverage (Cole, inpress; McAdoo, 1982). The recent emphasison community-based, family-centered care forchildren with special health care needs under-wores the nocessity for models that providethese services consonant with the cultural pat-terns of individual families (Koop, 1987). It is avery important step from the community-based, family-centered, and coordinated caremodel articulated in the Surgeon General'sConference (Koop, 1987) to a model which, inaddition to these efforts, provides service in aculturally competent manner.

The United States has a long history ofdeveloping service delivery models to provideneeded health, social, and educational ser-vices to recently immigrated families as theystruggle to adjust their lives to the new ways oftheir adopted homeland (Levine & Levine,1970; Wasik, Bryant, & Lyons, 1990). Effortsalso have been made at the federal level toprovide services to groups whose ancestralhome has always been America. These ser-vices are mandated through treaty arrange-ments as well as the recognition that NativeAmerican groups are citizens of the U.S. andare, therefore, entitled to equal access to ser-vices.

While some groups or individuals havemoved quickly into the mainstream, othersremain separate and maintain the lifestylesand language of their ancestral homelands.Still others retain some portion of their culturalidentity and adopt components of mainstreamculture in their daily lives. The heterogeneity

2

that exists along this continuum is as great asthe differences among families in general.This effort to preserve lifestyles and nonwest-ern practices in the face of complex social andpolitical forces which do not value them hasbeen a very difficult task. All of these lifestylesare equally valid possibilities. It is not incum-bent on families who immigrate to the UnitedStates to abandon tneir language, history,modes of interaction, religion and belief sys-tems and adopt a western view to becomeAmerican. In fact, many would argue that it isnot possible to do so because of the deeplyrooted value systems inherent in culture. Wewould argue that it is neither necessary nordesirable for families to do so.

To the extent that families do adopt west-ern styles, it is clear that they have not had aneasy experience in learning new modes ofinteraction and the language necessary tooperate within the complex systems of com-merce and daily exchange of America. Healthdelivery systems are no exception to this con-cern. If families have been motivated to seekhelp from a formal system of care, problems inlanguage, different patterns of interaction, andthe need to negotiate a complex system mayrequire a Herculean effort to reach the pointwhere appropriate and effective services canbe provided. If agencies invnlved have astrong commitment to providing services tofamilies in a culturally competent way whichrespects and encourages the belief systemsand patterns of interaction inherent in a familybackground, then this task is made somewhateasier.

Many ethnic groups have been chroni-cally underserved within the United States fora number of reasons. Some of these reasonsare based on the difficulties inherent in theprocess of change for any newly immigratedgroup. They may have difficulty in adjusting tothe political, economic service and interper-sonal systems of a different society. Other rea-

sons for this underservice are based on thelack of knowledge or interest on the part of theservice systc m to make services culturallycompetent by making them responsive to theunique needs of the various ethnic groupsthey are mandated to serve. This lack of ser-vice, combined with the increased immigrationfrom Third World countries, has created astrom mandate for outreach efforts that chal-lenge some of our traditional views of how ser-vices should be delivered and what servicesare appropriate. These new efforts require amore participatory model of program develop-ment that ensures strong participation of ethni-cally and culturally diverse groups in planning,implementing and evaluating new programs.Pragmatically, it is the only way gib workableprograms can be implemented and not meetthe fate of the program designers saying, "Wetried to help them, but we couldn't get them tocome in to the clinic." As we know from themovement to include families in decision mak-ing and program development as part of P.L.99-457, this inclusion strengthens the programin the long run. The same is true in creatingprograms that are culturally competent. Inclu-sion of constituencies in developing programsor a atate plan for services to the wide varietyof cultural groups living within its catchmentarea provides a solid base for program accep-tance and growth.

Programs and systems which have incor-porated the values and practices of family-centered, community-based, coordinated careshould find it a natural step to incorporate cul-tural competence into their philosophical andpractical orientation. Programs which remainunclear on the application of these family-centered concepts to their current programswill begin this effort at another starting point.The accompanying workbook provides a self-study guide to help programs at all levels increating family-centered, community-based,culturally competent systems of care. Pro-grams interested in more detailed descriptions

of the family-centered issues are referred to arecent publication by the Association for theCare of Children's Health (Shelton, Jeppson,& Johnson, 1987).

A recent conference on family support pro-grams and P.L. 99-457 enumerated a set ofbasic assumptions about families and pro-grams that serve them.

Strong community-based service systemsthat recognize the family-centered nature ofpractice share common beliefs about families,which include:

1. Families are composed of basicallycompetent individuals as well ascompetent caregivers.

2. The family is an important socialinstitution that needs to be preserved.

3. Families should and can make theimportant decisions about theirinteractions with agencies and ser-vice providers.

4. The rights and beliefs of the familyneed to be recognized and respected.(Roberts, 1988)

These beliefs about families lead to a set ofprinciples about the practice of family supportprograms and how services should be pro-vided:

38

1. Practices and services should bebased on the strengths, wants, andneeds of the family.

2. Practices and services should bedesigned to help families achieve theirown potential.

3. Practices and services should beculturally competent.

4. Practices and services should bebased on sound policy and designand must be Implemented by sensitive,caring, and well-trained staff.

5. Practices and services should beintegrated within the community andits other systems of services andsupports.

6. Practices and services must be builtupon a firm foundation of research andprogram development and continue tocontribute to that knowledge base.(Roberts, 1988, p. 5)

These principles should serve as a founda-tion for building strong culturally competentprograms. They recognize the primacy of thefamily unit and the rights of families to makedecisions about their own futures. Agenciesshould provide assistance and help conso-nant with the priorities set by the family. Con-sultation and support by the agency may benecessary to assist families in decision mak-ing, but it is recognized that family memberswill ultimately create solutions to problems thatare the best adaptations they can make basedon the cultural, economic, and psychologicalforces at work.

Agencies can facilitate or create barriers tofamilies coming to these solutions. A betterunderstanding of the competing forces operat-ing on a family will increase the likelihood thatthe agency will be seen as facilitative. Theemphasis here is on the cultural aspects ofthat process.

What Makes a ProgramCulturally Competent?

In our daily talk, we use the term "culture"in fairly loose ways to describe a set of beliefs,behaviors, and interactional patterns that iden-tify a person with a larger social or ethnic

group. Here, we distinguish between cultureand ethnicity. Within ethnic groups, there aremany cultures and subcultures, though somecommon history may be shared. Within thecontext of this monograph, then, cultural com-petence refers to a program's ability to honorand respect those beliefs, interpersonal styles,attitudes and behaviors both of families whoare clients and the multicultural staff who areproviding services. In so doing, it incorporatesthese values at the levels of policy, administra-tion and practice.

A multitude of terms have been used in thefield to relate cultural issues to practice.Among these terms are cultural competence,cultural sensitivity, cultural diversity, culturalrelevance and zultural awareness. We havechosen to encourage programs to employ theterm "cultural competence" for several rea-sons. Competence implies more than beliets,attitudes and tolerance, though it also includesthem. Competence also implies skills whichhelp to translate beliefs, attitudes and orienta-tion into action and behavior within the contextof daily interaction with families and children.

Importantly, these concepts have been dis-cussed in some detail in a recent monographby Cross, Bazron, Dennis and Isaacs (1989)with respect to minority children who areseverely emotionally disturbed. Cross et al.,define cultural competence as " a set of con-gruent behaviors, attitudes and policies thatcome together in a system, agency or amongprofessionals and enable that system, agency,or those professionals to work effectively incross cultural situations" p. 13.

Alternately, Hanson, Lynch and Waymanuse the term "ethnic competence" to decribethe need for early intervention programs tohonor the cultural diversity of families in pro-viding services. They cite a definition of ethniccompetence from Taft (cited in Green, 1982)which states "ethnic competence means act-

4 9

ing in a manner that is congruent with thebehavior and expectations of the members ofa particular culture."

Jordan et al. (1985) in describing a cultu-rally competent educational system, used thisphrase "coming home to school." In the pro-gram she describes, the educational system ischallenged to alter those key components ofthe school environment to reflect the socialorganization and learning styles familiar toHawaiian children in their homes. Importantly,the locus of the problem is not viewed as aninability of Hawaiian children to profit from aneducational experience, but that the educa-tional system is incompetent in developing anappropriate learning environment.

Likewise, culturally competent systems ofcare for children with special health needs donot ask families to accomodate their beliefs,attitudes and behaviors to those of the domi-nant culture but ensure that the systemchanges so that families feel like they are"coming home to the clinic." For a further dis-cussion of these concepts as they pertain toHawaiian children and education, the readeris referred to Tharp et al. (1984).

As stated earlier, cultural patterns aredeeply ingrained systems of social behaviorand beliefs. They are important determinantsof behavior, though other factors will alsoaffect how we act from moment to moment.Initially, outward manifestations of culture,such as dress, the color of our skin and thelanguage we speak may suggest stereotypesto someone who is meeting us for the firsttime.

When we have some notion of a person'scultural background in the absence of otherinformation about him or her, we may believethat their behavior is caused by their culturalidentity. As we get to know more, we under-stand the wide variety of forces which affecthow a person behaves; and that culture is one

of these determining factors. As such, it pro-vides a context to talk about how a family witha child with developmental disabilities reactsto the challenges they face and some of theissues which will be present in dealing withthe professional community assigned to helpthem and their child.

Bronfenbrenner's (1987) ecological modelof child development provides a useful heuris-tic to view levels of influence on a person'sbehavior as a series of concentric circles. Asone moves away from the epicenter of thesecircles, the influence becomes more subtleand less predictive of behavior moment tomoment, but very predictive of patterns ofbehavior available within an individual'srepertoire. It is this type of influence that cul-ture exerts on people. We learn our initialbeliefs and ways of interacting with oneanother from family members who areinfluenced by the community, which is, in turn,influenced by long-standing cultural patterns.The circles of influence continue to expand inthe ways alluded to above. What we arelearning, how we are learning it, and fromwhom we are learning it vary both by the situ-ation and the cultural patterns embeddedwithin the family and community structureswhich surround us.

However, individuals rarely remain withinone system. We are all part of several micro-systems which act like intersecting sets. Thesemicrosystems are not static but continue toevolve and mutually Influence each other. Ahandicapped child and his or her family is onemicrosystem in which the roles and patterns ofinteraction within it are defined. This samefamily becomes a part of another microsystemwhen it visits the physician, the physical thera-pist, the infant development clinic, the faithhealer, or a religious leader in the community.

Any family experiences some problems inlearning the new set of roles, rules, and

expectations when they become part of a newsystem that is designed to provide a servicefor that family. This experience is somewhateasier when the family system and the newintervention system share most of the samecommon concentric circles of influence (e.g.,as cultural patterns of interaction). In short,both the professional and the family membersknow how to behave and know the roles theother person will play in a broadly definedway. At a basic level, they may share a beliefthat the child's problem is caused by a medi-cal condition that is amenable to some form ofmedical intervention. They may also share abelief that the professional has knowledge thatwill assist the family to help their childprogress and develop as normally as possi-ble. At the level of daily interaction, they mayagree that (a) one does or does not shakehands when they meet, (b) eye contact isimportant or should be avoided, and (c) who inthe family should receive information and whowill be responsible to ensure that activitiesprescribed by the professional are carried out.

If the beliefs, interpersonal interaction pat-terns, and learning roles of the helping profes-sionals are very different from that of the fam-ily, the "givens" dc scribed above may not be"givensh at all. This reduces the chances thatfamilies will either use services that are poten-tially nvailable to them or follow through withthe prescribed regimens if they do get to theclinic. If families do persevere because of theirconcern for their child, these differences instyles will add additional stress to the parentand the professional. It can also make it veryproblematic for a professional to gain accessto information that is vital to diagnosis, treat-ment, and helping the family in decision mal.-ing. An Indian mother has described theexperience of many Indian parents in the fol-lowing way when she spoke on a training tapedeveloped by Southwest CommunicationsResources, Inc. to help sensitize professionalsto issues in native American culture:

6

CI CI CIJust like anyone else, it takes us time to get

used to working with a new doctor before wetrust him. More traditional families may takelonger. Some of us were brought up to avoidlooking directly at a person and not to askquestions. As parents, we care about our chil-dren, but sometimes we feel uneasy whenpeople ask us too many questions. In our cul-ture, that is often consider9d rude. If a nurseor doctor needs to ask a lot of questions, theyshould explain why they need that information.That helps us to feel more comfortable. Some-times the doctor doesn't even give us enoughtime to answer, so we often say nothing. Whenwe're not feeling rushed, there is time to thinkof the questions we need to ask. That is whywe often bring a relative with usthey can askquestions and help explain about the child'sillness.

When a serious decision must be made,we talk it through with extended family mem-bers or listen to our elders. Then, together wedecide what is best for the child. Some doc-tors get upset with us if we do not make animmediate decision on the treatment they rec ,

ommend for our child. But others respect ourcultural way of making decisions. They invitefamily members to take part in the discussionand give us time to decide what makes it mucheasier for us. Our traditional ways are impor-tant to us, and we respect them. We alsoknow some of our children have specialneeds, and we try our best to take care ofthem. Sometimes we use traditional methods;

other times we take the child to the doctor.1

The decisions and conflicts articulated bythis mother represent the basic issues familiesmust deal with daily in contact with health pro-fessionals. Families experience stress from awide range of sources when they discover that.heir child is developmentally different. Fami-

lies will seek help in times of stress from for-mal and informal sources, which helps toreduce this stress and bring the family back toa more harmonious, less stressful way of cop-ing. In this monograph, we refer to formal andinformal systems of support and care whichare part of a family's social support network.

As defined by Gottlieb (1981), "Social sup-port consists of verbal and/or nonverbal infor-mation or advice, tangible aid, or action that ispreferred by social intimates or inferred bytheir presence, and has beneficial emotionalor behavioral effects on the recipient" (p.28).

Informal systems of care include the meth-ods by which families solve problems withintheir own ecosystems of friends and family.For example, it may include a neighbor whocan always be relied upon to care for childrenwhen needed or who can help in housekeep-ing with elderly family members. The unclewho has a car and drives family members toimportant meetings or appointments is alsopart of this informal system.

Formal systems include those service pro-viders which have been sanctioned by societyto provide services of one kind or another. Apriest or medicine man is part of a more formalsystem and each carries honored ceremonialand social responsibilities. Within a westernhealth care system, professionals such asnurses, psyci,ologists, physicians, therapists,teachers and social workers are all part of aformal system, regardlees of whether servicesare provided in the home or the clinic. Laycounselors, aides, parent trainers and para-professional home visitors are all part of theformai system as well.

As you can see, this definition of formalsystems of care includes both western andnonwestern formal systems. You may beaccustomed to thinking of nonwestern formalsystems such as medicine men or shamans as

part of a natural system, traditional or informalsystems. We have chosen to include bothwestern and nonwestern healers in the formalsystem, and to distinguish them from informalsystems because they share common attrib-utes and perform important sanctioned formalroles in their respective cultures. They aresanctioned by their respective societies to pro-vide specific services; they may be reimbursedfor their services; they have undergone formaltraining and/or apprenticeships; and there is asystem of rules which relate to their behaviorand how one gains access to their expertise.

Though informal helping and support sys-tems are more enduring within families, thesesystems may need more technical expertiseand knowledge in areas vitally important to thedevelopmental progress of children with spe-cial needs. Informal systems probably will notbe able to teach parents how to perform heal-ing ceremonies as would a medicine man orhow to operate a home ventilator as would arespiratory therapist.

In most cases, nonwestern formal systemsare more compatible with informal systemsbecause they are of the culture and derivetheir legitimacy from the belie '. systems andvalues held by members of that cultural group.Unless western formal systems such as clin-

ics, hospitals, schools and early interventionprograms are designed to be compatible withthese nonwestern formal and informal sys-tems, it is likely that families will not gainaccess or use the information they need.

There are other barriers to the use of ser-vices by culturally different groups beyondthose mentioned above. Families may lackinformation about services in general or whatspecific services a clinic could provide. At amore basic level, they may not see the rele-vance of a formal intervention regarding thedevelopmental problems their child may beexperiencing. Further, families may hold differ-

7 1 2

ent beliefs about the causes or the nature ofproblems that are viewed in our western tradi-tion as medical or developmental in nature.Each culture has a mechanism for dealingwith these issues, which is constant with itsbelief systems. The goal of a culturally com-petent program is to bridge the gap by makingtreatment and related services relew At to cultural patterns. Families then have a choice intreatment where none existed before.

The goal of a culturally competentprogram is to bridge the gap bymaking treatment relevant to culturalpatterns.

Another Indian mother speaks for manyIndian parents when she talks about the inter-play of the two systems.

0 0 0To my people, having good health means

living in harmony within ourselves and ourfamilies. We see illness as a disharmony, andit cannot be separated from the mind andspirit. We respect western medicine and thedoctors, but sometimes it's better for us to usetraditional healings and medicines. Our relig-ion is woven throughout our lives, but thesethings are very private. We may find it difficultto be asked directly about our beliefs and cer-emonies by those not of our tribe, but some-times we use traditional medicine for a familymember in the hospital and appreciate medi-cal staff cooperating and understanding. We

just want them to respect ourprivacy.1

The recent emphasis on community-based,family-centered coordinated care for childrenwith special health care needs creates theopportunity to help bridge this gap betweentraditional practices and western systems ofcare. By emphasizing the community-basednature of programs, it is more likely that theculture and mores of a family will mesh with

that of the agency providing services. Agen-cies at the community level are more likely tobe responsivo to community concorns andinput. As suggested above, programs that arefamily centered are more likely to solicit andbe responsive to family involvemeot in treat-ment. They are more likely to accept a family'sdecisions about priorities and to create theconditions under which a family is able tointeract effectively with professional staff.These values, which are part of community-based treatment programs, suggest the valuesthat must be present in culturally competent,community-based, and family-centered coordi-nated care for children with special healthneeds.

Types of ProgramsProviding Services

Different types of agencies are more orless likely to be able to provide culturally com-petent support to families. For purposes ofdiscussion, four types of programs are pre-sented. A recent publication describing cultu-rally nompetent services within the mentalhealth field identifies these four models forservices (Cross, Bazron, Dennis, & Isaacs,1989):

1. Mainstream agencies which provideoutreach to minorities.

2. Mainstream agencies which supportservices by minorities within minoritycommunities.

3. Agencies which provide bilingual/bicultural services.

4. Minority agencies which provideservices to minority people.

In the first case, a mainstream agency suchas a local hospital or state division of maternaland child health may identify a need to beginservices to a previously underserved minority

8 1 3

population within its catchment area. Thisagency begins an outreacn effort to serve Wsgroup. Unless they have taken great care toensure they are family-centered and commu-nity-bared, the agency could be seen asinsensiti -I to the cultural concerns of the tar-get group simply because it is either part of thestate bureaucracy or is "that hospital on thehill." The mainstream agency must be able tobe sufficiently flexible to create trust within thelocal community and to build a strong commu-nity support for its activities with meaningfuland consistent guidance provided by commu-nity representatives and the parents involved.It must be able to deal with ambiguity and towelcome the opportunity to alter proceduresand services to meet the expectations ofanother cultural group before that group canbegin to trust the agency and work with it.

Frequently, large institutions have difficultydeveloping or maintaining the flexibility tooperate at this level of community responsive-ness. Other workbooks within this seriesdetailing issues in the development of commu-nity-based networks and programs will serveas a useful guide in helping programs todevelop this emphasis if it is not alreadypresent (see reference list under RainbowSeries). The important point here is that main-stream institutions will find it particularly diffi-cult to develop culturally competent programsif they have not simultaneously or previouslymade a serious commitment to family-centered community-based services.

The second model involves a mainstreamagency sponsoring a community-based pro-gram that is staffed by members of the culturalgroup which it serves. The Southeast AsianDevelopmental Disabilities Prevention Project,which will be discussed in some detail in thenext section, is an example of this model inaction. A larger umbrella organization spon-sors a program for recent southeast Asianimmigrants whose children are at risk for orhave developmental disabilities. The program

is located away from the main center in thesection of San Diego that is home for manynew immigrant families. The staff is almostentirely made up of representatives of the vari-ous ethnic groups targeted in the program.

This model recognizes that mainstreamse! vices are not appropriate for the targetcommunity, and that a very different responseis needed in order to provide these neededservices to families. The physical and admin-istrative separation of the program from theumbrella organization allows for the autonomynecessary for the program to flourish. At thesame time, the umbrella provided by thislarger organization makes it possible toreduce the administrative overhead of newprograms. Staff from the umbrella programare available to consult and advise in programand administrative matters as needed to assista new program in getting started.

The third model involves bicultural andbilingual programs that emphasize the multi-cultural aspects of a community and strive toprovide options for families within a main-stream setting. Staff are recruited who caneffectively enter into the microsystem of thefamily both because they speak the natal lan-guage of the family and they have relevantexperience living within the cultural nicheshared by the family. However, since the staffis also bicultural/bilingual, they will have hadsufficient relevant experience within the main-stream culture to act as effective brokers andnegotiators in getting needed services in thesystem for a family. Families are more likely torelate to the staff who can speak their lan-guage, and the staff are more likely to be ableto identify the issues of concern represented inthe family. Typically, staff within such pro-grams are professionally trained, though somemay also be at the paraprofessional level.

Programs seeking to become bicultural/bilingual face several obstacles including

914

intarnal staff resistance to changes in hiringcriteria and job qualifications. The move to abicultural/biingual staff requires a close exami-nation of job descriptions to ensure that theseskills are present in staff. Other sections of thismonograph and accompanying workbook dis-cuss this issue in more detaii. Here, it isimportant to note that the commitment to hiringbilingual staff may be challenged by chargesof lowering standards, reverse discrimination,lack of qualified applicants, etc. All of thesechallenges can be overcome with involvementof community and family members in decision-making and a willingness on the part of exist-ing staff to closely examine their own biaseswithin the area.

The fourth option involves agencies thatare entirely composed of a cultural minorityserving that population and doing so withoutthe support of an umbrella mainstreamagency. These programs may have the high-est degree of autonomy and self-determination. Such programs may be difficultto sustain because of the complex nature ofmaintaining their funning. Groups that main-tain themselves distinct from the larger main-stream culture may be less finandally stable.Consequently, they must rely on funding fromstate or local agencies who may not value theservice being provided or who may offer theservice through one of the other options men-tioned above.

Despite the funding difficulties these pro-grams may face, grass roots efforts are multi-plying within communities at the local level.Their persistance suggests both that main-stream systems have not met the needs offamilies and that community ownership andcultural competence are strong values whichwork together to ensure that families areappropriately served. Smaller grass rootsefforts may not be able to provide more spe-cialized and technical help because it is oftentoo expensive and beyond the expertise of

10

such programs. Crisis services and outreachefforts in support of families are services whichare frequently offered. Free-standing or store-front clinics are another example of this type ofprogram. Professional volunteers may provideservices that would be too costly othemise.

One such program in Hawaii involved alocal group that identified natural helpers inthe community and provided training and sup-port for these individuals to work with familiesin crisis. The program was primarily staffed byand served native Hawaiians. Funding wasprovided through small grants from the AlohaUnited Way and some state funding by theState Department of Mental Health. Profes-sional staff wero few. Most were paraprofes-sional. The staff were highly motivated andvery committed to their program. Serviceswere delivered at low cost, and referrals weremade to other programs in the communitywhen appropriate.

Another example of this type of program isAvance, which serves primarily low-incomeHispanic families from the barrios in San Anto-nio and Houston. Over the past 16 years, ithas grown from a program funded by a smallgrant of $50,000 to a much more extensiveeffort including multiple sites and multiplefunding sources. It has, however, maintaineda consistent theme of its community-based,locally controlled beginnings. Over 80 percentof its staff are from the community, and havegone through the program.

Avance is an important example of thistype of effort for several reasons. It providesappropriate role models for individuals in theprogram. It also provides employment for asignificant number of families who were previ-ously unemployed. Also, it demonstrates thatgrass roots efforts can continue to grow andmature without losing the very important com-munity base of their original efforts. As theygrow, they are able to exert influence on staff

agencies by the example they set and the cul-tural competence they bring to all of their inter-actions with mainstream agencies. Finally, itshares a common thread with other culturallycompetent programs in the valuable service itprovides to families who, for a number of rea-sons, do not utilize mainstream services.Such programs provide a variety of services intheir own right to families, and also help fami-lies gain access and utilize services providedby mainstream agencies.

Issues in Policy and Practice

We have said that a culturally competentprogram is community-based, but it is morethan that. What are the additional componentsthat must be present for a program to work?These issues involve several areas of pro-gram design and include policy, practice, andtraining issues. Each model described abovecan move toward better services in thisdomain as they consider issues discussedbelow.

PolicyPrograms that are culturally competent do

not become that way by accident. They areculturally competent because of a commitmentat all levels within an organization to provideto all families services which are consistentwith their cultural beliefs and styles of interac-tion. This is a clearly established policy;understood and publicly stated so that bothstaff, clients, and the larger community areaware of this orientation of the program. It

may be formally stated in long-term plans orpart of the written philosophy statement withinthe organization. It should make clear that thestate/agency/organization is committed toserving all children who fall under their esta-blished medical and developmental guide-lines within their catchment areas. This infor-mation should not be filed in the minutes of ameeting, never to see the light of dayl For it torepresent an effective policy decision, it must

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be broadly understood within the organizationand its constituency. It must be disseminatedthrough the formal and informal channels thatexist within the community. In short, the policymust be a living part of the organizationreflected in its practice and administration.One way to ensure that policy is followed is tocreate the circumstances in the daily policymaking structure of the organization whichrequire that constituents' cultural concerns aregiven voice. Members of ethnic and cultural

-oups, including parents and communityIbaders, must be well represented in policy-making groups. For example, the makeup ofState Interagency Coordinating Councilsshould reflect the cultural diversity of a state.Local service provider agencies shouldensure that members of the community beingserved are adequately represented on boardsthat make real decisions about how the pro-gram is to function. It is only as an agencybegins to work with natural leaders within acommunity that it can begin to translate anintended purpose into a reality. This process,if successful, will change the ways an agencyoperates in policy formation, "iring, training,and daily delivery of services. It may alsochange the intended purpose. For these rea-sons, agencies should be clear from thebeginning if there are areas that cannot beeasily changed. If there are non-negotiableitems and ones which are not open to commu-nity input, these parameters need to be madeclear to participants as the process begins. It

is then up to the community members todecide the degree to which they can operatewithin the constraints imposed. As this processunfolds, the policy-making body, whichincludes community participation, will be ableto set standards of practice that reflect a cultu-rally competent, community-based, and familybased approach.

An example of how a constituent concerncan change the direction of a program can befound in a report of a community needs

assessment conducted by Ymori and Loos(1985). A program for ethnic Hawaiian preg-nant and parenting teenage mothers hadbeen in operation for several years when amore formal network of services was formed toprovide better case management for this pop-ulation. The first step was a felt needs assess-ment in which agencies and clients were sep-arately asked to rank order a number of needsand potential services that could be providedby the agencies in the network. Agencies ingeneral thought that the teenage mothers inthe program were most in need of the follow-ing services: parent training, couples counsel-ing, birth control counseling, and job training.Teenage mothers, on the other hand, listed adifferent set of needs as their highest priority.These included a permanent home for them-selves and their children, a reliable child carearrangement so they could continue theirschooling, and food stamps so they could eat.This information was used in interesting ways.Neither group was made to feel that their listwas "wrong." Rather, each group had anopportunity to see the list of the other groupand to talk with them about the differences inthe two lists. The result was a better under-standing both on the part of the teen mothersof the agency concerned and a commitmenton the part of the network to help the teenmothers to meet some of these primary needs.

PracticeThe creation of a community-based, cultu-

rally competent family-centered program is nota static event but an ongoing creative colla-borative process. There are several guidingprinciples which may help to ensure that theintended policy of culturally competent ser-vices is translated into an ongoing effort toshape practice. These include:

1. Culturally competent services must be,by definition, also family-centered andcommunity-based. The principles ofpractice enumerated on page 3 of this

12

monograph underline the principlesdescribed here.

2. Staff should be aware that families areunique and must be treated uniquely.It is as culturally insensitive to assumethat all families within a given culturalgroup will react the same way as it is toignore the fact that culture is an impor-tant variable in determining how webehave.

3. Care must be taken in separatingcultural issues from the effects of pov-erty and discrimination experienced bymany minority groups within the UnitedStates. For instance, the economics ofbeing poor may require models of childcare different from ones which are cul-turally preferred. Families may havefew options and resources at their dis-posal, and these resources dictate themost economical ways of providingcare.

4. Program staff should have the capacityand opportunity to assess for them-selves their own cultural values andunderstand the impact of their back-grounds on their ability to provide cultu-rally competent services. This culturalself-awareness is an ongoing discoveryprocess and can be a valuable tool indefining new program and trainingneeds.

5. it is not necessary to be of a culture toprovide services to members of that cul-ture. However, it is important that staffunderstand the dynamics of the inher-ent tension caused when two or morecultures interact to provide a service orsolve a problem. It is critical to ensurethat members of the cultural groupbeing served are able to effect deci-sions concerning practice, training, hir-ing staff and policy.

6. It is recognized that gor d programs arethe product of hard work in developingpersonal relationships and networksacross agencies and communities.Even so, mechanisms are needed toinsure that components of a programhave been institutionalized and are notdependent on one person from theinstitution and one person from thecommunity to maintain them over time.The commitment needs to be at theinstitutional level with sufficiently broad-based involvement that the institutionalcommitment survives staff turnover andchanging interests.

7. Th9 development of programs such asthese requires a paradigm shift on thepart of service providers to share own-ership and decision-making. As withmany shifts of this nature, once pro-gram staff and administrators make thatshift, it becomes a very natural way ofviewing the world. However, such ashift is not without risk. It requires ahigher tolerance for ambiguity as pro-grams, parents, and community leadersmap a course together. Those whoenter into the process, however, have"le potential to create programs with ahigh degree of community and familysatisfaction. This leads to higher staffmorale and higher calibre level of ser-vice.

Specific Issues 9.n Practice

The principles described above related topractice affect a number of areas in practice,including assessment, outreach, familyinvolvement, evaluation, and staffing. Eachwill be separately addressed below.

AssessmentPrograms working with culturally different

populations face a particularly critical issue in

providing an appropriate assessment of youngchildren with developmental or medical prob-lems. If standardized assessment tools areused, there are problems in translation of com-ponents into the natal language of the child,as well as lack of appropriate norms forgroups other than those included in the norm-ing sample. The additional possibility existsthat the tests contain an inherent cultural biasthat discriminates against children of differentcultures. As an example, the PREP programin Hawaii, discussed in more detail in the nextsection, conducted routine language testingon all of the children in the program. Sincemany children lived on or near the ocean, par-ents and neighbors would keep their boats forfishing in the backyards. One of the standardquestions in the battery was, "Where do youfind a boat?" The correct answer, according tothe manual, was "on the ocean or in thewater." Many of the children in this programwould answer "in the backyard" or "in thedriveway." Though this situation is humorousat one level, the program was confronted withthe dilemma of following the manual orrenorming the test. Programs and states mustcarefully review their eligibility criteria for ser-vices to ensure that they do not contain cultu-ral biases that would either overinclude orunderinclude children of culturally differentgroups in their criteria.

Programs and states must carefullyreview their eligibility criteria for ser-viva to ensure that they do not containcultural biases....

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8

The goal of any assessment should be topoint the way that professionals can be helpfulto families in maximizing the developmentalgrowth of their child. Deficiency and deficitmodels of assessment do not serve this pur-pose. The inclusion of the "at-risk" categoryunder P.L. 99-457 is particularly worthy of notein this regard. Care must be taken to ensure

that children are not "at risk" primarily becauseof cultural differences.

Issues in assessment go beyond what isassessed. "Who" is involved in assessmentcan be as important as "what" in developingan accurate picture of a child's strengths andneeds. As noted earlier, the decision-makingpatterns within a family must be understood inorder to ensure that complete information isreceived. If families generally defer to thegrandparents or if the father is the traditionalspokesperson for a family, these patternsneed to be reflected in the informationexchange which is part of the assessment/intervention process. If the parent feels mostcomfortable in talking when a member fromthe extended family is present, it is importantto create the atmosphere and the opportunityfor all concerned to participate. Additionalissues in family assessment will be discussedin a later section on family involvement.

The major point here for programs toremember is that assessment of children andfamilies is a clinical skill. This skill involvessensitivity to and an understanding of the cul-tural niche which constitutes the world ofexperience for a family. The clinician musthave knowledge of and experience with thefamily's background in order to provide a validassessment that accurately describes thechild's current level of functioning, that child'spotential for continued growth, and the sup-ports available to the family.

OutreachPrograms and states must carefully

develop an outreach effort that invites cultu-rally different groups into the service system.Though it is appropriate to develop informa-tion pamphlets about a program in the nativelanguage of the target group, this is just abeginning of a strong outreach program. Caremust be taken to ensure that materials arecompetently translated into concepts mean-ingful to the target population. A recent exam-

14

ple serves to reinforce the need for care inpreparing materials. A program was translat-ing a child abuse pamphlet from English into asecond language. The original document hada picture of a young child on the cover with thecaption "This child is a victim of child abuse."The translation was made and the pamphletwas distributed. The agency discovered aftersome time that the term "child abuse" hadbeen incorrectly translated into "This child hascommitted a crime."

Outreach begins with an effort to discoverthe number of children within the target areawho meet the eligibility criteria for service andio compare that number with those who areactually receiving services. There are severalways to begin to develop an estimate of thenumber of eligible children once the criteria foreligibility are firmly established. One methodis to develop an accurate estimate of a givenpopulation in the catchment area. For exam-ple, eight percent of the total population in astate or a catchment area may be of a particu-lar ethnic or cultural group, and yet only twopercent of the actual client load is of this ethnicor cultural group. In this case, only one of fourchildren who are probably eligible for servicesare receiving them. If the conditions whichmake a child eligible for service are exacer-bated by conditions of poverty and substan-dard living conditions, the 8 percent estimateis probably an underestimate of the real inci-dence in the community. Still, this can be abeginning point for programs to monitor theirprogress in attracting minority clients.

Alternately, if good birth records exist forchildren in a catchment area, one can esti-mate the number of children a program shouldbe serving based on the known incidence of adisorder or developmental problem within thatpopulation. The Indian Health Service, forinstance, has excellent birth records on allchildren born on the Navajo reservation andcan state with some certainty the numbers ofchildren born with a variety of disabling condi-

9

tions within the Navajo nation. Again, thisleads to a way to monitor progress in leachingeligible children and families. Acquired condi-tions, however, are not covered in this proce-dure.

Knowledge of the numbers is Step 1 in out-reach. Recruiting community support forthe programs is Step 2. The issues dis-cussed above with respect to communityinvolvement are central to a good outreacheffort. Often, members of community networkknow which children would benefit from ser-vices. They can be a valuable ally if tappedand invited into the system. The reader is alsoreferred to other workbooks in this serieswhich specifically address the issue of com-munity involvement in program developmentfor a more thorough discussion of theseissues.

Family InvolvementService providers and planners have grad-

ually come to realize the enormous benefit tochildren when famiiy members are routinelyinvited into the entire process of assessment,care, and treatment. This is no less so for fam-ilies from cultural or ethnic minorities. Fami-lies within a given ethnic or cultural group varywith respect to patterns of interaction, familysize, authority roles within the family, and deci-sion-making processes. However, there aregeneral patterns that are seen as enduringtrends within a group and can serve to guide aprogram as service providers learn moreabout an individual family and how these rolesare assumed within that family unit. A recentpublication by the National Center for ClinicalInfant Programs describes some of these gen-eral themes by cultural groups (Anderson,1989).

The important lesson a number of pro-grams have learned in working together withfamilies is that cultural styles of interaction arestrong predictors of family patterns. Even if

15

families move away from many of the tangiblemanifestations of their culture over time, pat-terns of interaction within the microsystems ofthe family are likely to remain. Thus, a family'slanguage may change to English, and westernforms of clothing may be adopted as well aswestern foods. Members of the family whohave frequent dealings with the mainstreamculture may adopt many of the interactionalstyles of the group while they are involved withmainstream people. Even as all of thesechanges take place, the patterns of interactionand rituals within the family unit as defined bythat culture are much less likely to beinfluenced by external forces.

The enduring nature of these private familypatterns is particularly relevant in times of cri-sis and stress when family members turn toone another for support. The problem-solvingstrategies and internal uses of resources tomanage the stress are probably those of thenatal culture. Professionals are initially mostlikely to come into contact with the family pre-cisely at the time that these strategies arebeing mobilized to handle the birth of a childwith a disability or the discovery of medical ordevelopmental problems with an older child.This is the hardest time for everyone; yet it isthe most critical in terms of developing a long-standing bond with a family which will allowagencies to continue to provide quality ser-vices to the family and target child. If theagency representative ignores the authorityrelationships and decision-making processesthat the family uses and imposes another sys-tem on the family, it is very likely that the familyeither will not return for treatment or willbecome what the agency may see as a prob-lem family, resisting suggestions and onlyminimally following regimens.

The concepts discussed above are notspecific to culturally different families. Again,we are reminded of the natural step from com-munity-based, family-centered care for chil-

20

dren with special health needs to culturallycompetent program development. An excel-lent publication by the Association for the Careof Children's Health provides a great manyinsights into the issue of family-centered care(Shelton, Jeppson, & Johnson, 1987). All ofthe issues raised in that publication are rele-vant to culturally competent programs andexpand upon the concepts enumerated in thisdocument.

StaffingUltimately, the way people from agencies

interact with people who are seeking servicesis the critical variable in whether or not a pro-gram is perceived to be culturally competent.The bottom line in many of the issues dis-cussed thus far has to do with the qualifica-tions, training, and support provided to thestaff who interact daily with clients. In this sec-tion, general issues in hihng, training, andsupporting staff will be discussed.

A wide range of staffing patterns existwithin programs which serve cultural minori-ties. Many positions that require licensurehave built-in standards with respect to the pro-fessional qualifications that must be met. Posi-tions such as home visitors may be filled eitherby professional or paraprofessional staffdepending upon the skills required and thetypes of assignments the staff person isexpected to complete with the family. Otherpositions such as aides are more clearly at theparaprofessional level.

A recent conference on family support inthe home suggested a minimum set of qualifi-cations for home visitors, but this set of qualifi-cations has broader applicability to all individ-uals working with families. In addition to theprofessional qualifications set by licensingboards or the technical knowledge requiredfor a specific position, they must have goodinterpersonal skills, organization, effectivecoping skills and problem-solving abilities,

and relevant prior experience, which need notbe in the ,orm of a paid position (Roberts,1988).

Relevant prior experience for staff workingin programs with cultural minorities shouldinclude experience in working with culturallydiverse populations. Since job descriptionsand advertisements for positions should spe-cifically state the skill,: necessary for a personto be effective within a particular job, positionswhich require staff to provide services tominority groups should require skills in thisrespect. The staff need not be of the culture tobe able to serve families within that culture,but other types of relevant experiences areneeded to ensure that the cultural differencesof families and all staff are honored. This train-ing can come from a number of sources,though it is doubtful that formal instructionalone (e.g., coursework at a university) wouldallow a person to have the requisite depth ofknowledge to translate theoretical informationinto everyday practice.

Programs serving minority and culturallydifferent populations are interested in provid-ing the highest standard of service possible,but competing demands create constant ten-sion in defining who should provide this ser-vice. Frequently, it is very difficult to hire indi-viduals with all of the relevant experiencenecessary to be effective within a particularposition. In placing a high value on relevantexperience with different cultural groups, pro-grams may be particularly interested in minor-ity candidates for a position. There are fewerprofessional staff with formal degrees availa-ble from minority groups than from Caucasiangroups. Though professional schools areworking to address this imbalance, thedemand for professionals from minorities iskeen, and programs may not be able to hiresomeone with the relevant life experienceswithin a culture as well as the professionalqualifications to work in their program. An

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21

applicant may have the professional qualifica-tions for a position but no relevant culturalexperience. Likewise, ari applicant may haveconsiderable experience with a given popula-tion but lack important professional qualifica-tions. In either case, programs are confrontedwith having to make choices between variousqualifications for applicants. Programs whichdo ensure that they have a culturally compe-tent staff will gain many benefits from doing so.Services to families will be more effective.Staff will have more opportunities to learn fromone another. There are no easy solutions toreaching this goal. Programs may wish to takeinto consideration several factors in makingthese hiring decisions.

First, how does this person's skills fit intothe constellation of skills represented by otherstaff members with whom he or she will beworking? If the candidate brings skills not rep-resented by others and has the relevant cultu-ral background, perhaps some of the otherduties could be shifted to other staff during atraining period for the new staff person.

This leads to a second issue. What typesof supervision is available within the agencyfor new and existing staff? If this person willbe working in a situation with minimum sup-port and supervision, there will be little oppor-tunity to learn new skills not present when theperson is hired. On the other hand, somemissing skills may be more easily learned onthe job if a full inservice training program isavailable and supervision is routinely pro-vided, or if opportunities for peer supervisionand case conferences are available. Commu-nity members can be a valuable source ofinformation and faculty for inservice efforts.

The personal characteristics of applicantsobviously are important issues in the decision.Are they flexible with a history of being able topick up new information and use it effectivelyin new situations? Do they display an open-

ness to learning and to differences amongfamilies? Are they family centered in their atti-tudes toward intervention?

Finally, the involvement of the communityin the hiring practices of a program will help inmaking the hard decisions, such as those sug-gested above. Some programs feel more com-fortable allowing and encouraging communityinput into the hiring process than others. Thisis an individual program decision. Each com-muniV will differ in their priorities concerningstaff hiring. Some may see professional quali-fications as paramount, while others may bemore interested in a blend of professional andcultural qualifications. Parents can be valua-ble allies in this effort and provide importantinformation about how comfortable they arewith potential staff. Parents are resourceswhich should be used.

Use of TranslatorsIt is also important to consider problems in

language and communication in staff patternsfor clients/patients whose native language isnot English. If community members know thattheir initial point of contact with an agency willinvolve someone who speaks their language,then one barrier to seeking services is alreadygone. Some programs have decided to use areceptionist or secretary who is multilingual

If community members know thattheir initial point of contact with anagency will Involve someone whospeaks their language, then one bar-rier.to seeking services Is already

gone.

and speaks the languages of the populationsto be served. The receptionist at the South-east Asian Developmental Disabilities Preven-tion Project in San Diego, for instance, com-municates fluently with families in Laotian andHmong and is able to identify Vietnamese and

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Cambodian languages and connect the familywith the appropriate counselor.

Many times programs will need to think ofinnovative ways to provide service in the lan-guage of the family if workers within the pro-gram are not of the culture. The most cultu-rally competent way to provide services is byhiring staff who speak the language of the cul-tural groups to be served. Though this mayraise many challenges for a program, it isclearly the most preferred and sensitiveoption. If a program is experiencing difficultyin hiring staff with the appropriate languagecompetencies, it may need to review its hiringcriteria and policies to ensure that the impor-tance of this skill is appropriately emphasized.Program staff who have reviewed this manu-script have emphasized the interim nature ofthe use of translators. It cannot be a long-termsolution because it suggests a lack of commit-ment to families whose native language isother than English. When programs find theyhave no immediate alternative other than theuse of translators, it is preferable if translatorshave experience with families and can be con-sistently available each time a particular clientis in the clinic. Otherwise, a new interpersonalrelationship has to be established each time.Some clients who do speak English will stillprefer to use their native language and atranslator, because it is easier to understandconcepts and provide information during theinterview, Every effort should be made to pro-vide translators to clients so that the interviewcan be conducted in the language that is mostcomfortable for the client.

Client LoadPrograms that are family based and cultu-

rally competent must take the time necessarywith individual clients/patients to ensure thattheir needs are being met. It takes more timeto provide these services than one might findin programs which do not have this focus.Many clients are not only unfamiliar with the

educational, social service, and health careservices available to them, but do not under-stand the reasons for their necessity. It takesconsiderable time to explain the rationale forservices as well as to develop a plan whichincorporates both traditional approaches andwestern approaches to the problem. This isthe core of culturally competent, community-based care and is essential for program effec-tiveness. Unless staff are able to spend therequired time with clients, these goals of theprogram will not be met. Therefore, caseloadsmust be adjusted as required to allow thenecessary conditions for this relationship todevelop. The average caseload in a homevisiting program in Hawaii, designed to helpnative Hawaiian families maximize the health,social, and educational outcomes of their chil-dren, was 12-15 families per full-time homevisitor. An even lo er caseload may benecessary in situations where families arenew immigrants and do not speak English orare on reservations where driving time eitherto the clinic or to a client's home may be sev-eral hours.

It is also important to consider the period oftime over which contact may be necessarywith families. In family support efforts, contactmay be required for several years until familymembers feel competent to handle the sys-tems of care with less assistance. /n somecases, families will never feel completely com-fortable and would be unable to serve as theirown case managers within the system. Here,agencies must make hard choices withrespect to following a given family for anunlimited amount of time or to shift resourcesto a new family.

Professional-ParaprofessionalPartnerships in CulturallyCompetent Programs

Programs serving cultural minorities mayfind that they use some combination of profes-sional and paraprofessional staff more fre-

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quently than other programs. Some of thereasons for this nave been discussed abovewith respect to decisions programs must makein hiring practices. Other reasons have to dowith the possibility that good programs mayseek out and hire program parents or othercommunity members to work in the program ina number of capacities. In many cases, theseworkers will not have degrees and will fill par-aprofessional positions. Care must be takento ensure that the appropriate supervisory andconsultative roles are clearly defined withinthese relationships. Paraprofessionals fromthe community have much to offer professionalstaff with respect to the value systems andinteractional styles of a cultural group. Unlessmechanisms are developed to ensure thatcommunication, education, and mutualrespect are two-way streets, &,his knowledgemay not be made available, and, conse-quently, services will be less culturally compe-tent.

Training and SupportThis leads to the final issue with respect to

staffing, training, and support issues in cultu-rally competent programs.

Inservice training programs should attendto both the affective and content-orientedneeds of staff in working with culturally diversepopulations. As noted above, opportunitiesshould be provided that invite staff, in a non-threatening and supportive way, to explore theimpact of their own cultural heritage on theirprofessional relationships with families.

In addition, information about cultural prac-tices should be openly presented by the mostqualified people. This may include parents,community representatives, leaders within acultural group, or other staff. It must also berecognized that certain cultural practices arevery private events and are not typically dis-cussed or shared outside of the cultural group.This practice must also be respected. For

instance, it is sufficient to know that Indianfamilies may want modicine people to performtraditional ceremonfds in a hospital room of asick child, and that certain objects used in theceremony may be left there and are not to bedisturbed. Staff outside of the culture do notneed to know more than this. They canrespect and support the rights of the familywithout intruding on private and deeply feltreligious beliefs.

Staff working with families from variousethnic and cultural groups need a supportiveatmosphere in which to work. Though this isno different from staff in any program, it stillmust be emphasized because of the high turn-over and staff burnout experienced by manyprograms. Reinforcers for staff may be fewand widely spaced. One home visitor reportedworking with a new immigrant family for twoyears before the family consented to allowtheir deaf child to be tested. In this period, thechild's language had not developed, andother developmental milestones had beenseriously delayed. The home visitor hadworked very hard with this family and felt justi-fiably proud that he had stayed with them forthe period necessary to help them make thedecision to have their son seen by westernmedicine. Without the strong support that thehome visitor received from his peers andsupervisors, it could have been very discou-raging to continue to support a family in thisvery slow decision-making process.

SUMMARY

din this section of the monograph, princi-ples of community-based, family centered, cul-turally competent care for children with specialhcalth needs have been discussed. The pointhas been made in several ways that it is asmall but very important step from community-

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based care with a family focus to one whichalso incorporates cultural issues in programdesign and implementation.

Programs in Action

This next section reports the results of aninformal survey of programs funded by theBureau of Maternal and Child Health, whichserves cultural or ethnic minorities and takesseveral programs across the country that havebeen recognized as examples of these princi-ples in action and presents important aspectsof each program. The descriptions are notintended to completely describe all of the com-ponents of each program but to highlightissues.

Informal SurveyIn preparation for writing this monograph,

all of the programs funded through the uureauof Maternal and Child Health and ResourceManagement in 1988 that mentioned a cultu-ral or ethnic minority in their publishedabstract were interviewed to glean commonissues among the programs.

First, without exception, project directorswere willing to facilitate our efforts. Projectswere focused on either serving ethnic or cultu-ral minorities or working with specific prob-lems within a cultural or minority group (e.g.,genetic counseling services). Invariably thestrongest point from each interview concernedthe advisability of involving members of thecommunity in the project. Service deliverywas more sensitive toward cultural needswhen an attempt was made to include commu-nity members in the decision-making pro-cesses, planning process, or employing per-sons from the community in the interventionand implantation of services.

Programs that seemed most successful inproviding services to cultural minorities were

ones which adopted a more flexible and rea-listic attitude toward their program. For exam-ple, a project was involved in working withHispanic women and infants on the Texas/Mexico border who frequently traveled backand forth across the border. Health caretended to be noncontinuous, and a close rela-tionship with the counterparts in Mexicoexpedited more effective health care. Foodvendors at street stands represented a healthhazard for program padicipants in small Mexi-can villages. Rather than closing down thevendors who would probably open up againsomewhere else, an education programaimed at increasing the frequency of handwashing was implemented with some suc-cess. A Mississippi outreach prenatal educa-tion project also gave an example thataddressed a practical issue to increase pro-gram viability. Providing transportation to themothers and infants between their homes andthe center increased the numbers of individu-als served.

Certai.i themes among the most successfulprojects included the following:

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1. Flexibility. It was important to havethe ability to place the project's ownagenda on temporary hold and listen tothe needs of the community. Compro-mises and adaptations were frequentlynecessary. Most often, the projectsevolved to include more communityinput as they moved along in develop-ment.

2. Sensitivity. Certain behaviors hadspecific meaning to a particular culture,and successful communication oftenentailed understanding that meaningfor the people that the project was serv-ing.

3. Trust. Trust took time to develop, itwas often aided by soliciting the sup-

25

port of an important community member(i.e., church leader). Consistency andfollow-through were mandatory charac-teristics if the relationship was todevelop into one which included trust.

4. Recognition of priorities. Moresuccessful programs understood that ifthe family was not having more basicneeds such as food and shelter met, itwas unlikely they would listen to some-one lecturing about preventive healthcare.

In summary, most projects took the timeand had sufficient respect for the communitieswith which they were working to find out aboutthem and involve them in the partnership forprogram development.

PROGRAM DESCRIFIIONS

KAMEHAMEHA SCHOOLSPREKINDERGARTEN EDUCATIONALPROGRAM

The first program to be described (PREP) isa community-based early intervention pro-gram drawing on the strengths of contempo-rary Hawaiian culture and involving education,health, and social service providers to createprograms for Hawaiian families with youngchildren. The sponsoring organization forPREP is the Kamehameha Schools/BishopEstate, which is a private school system dedi-cated to developing cn-campus and outreachprograms for ethnic Hawaiian families. ThePREP project was partially funded by theOffice of Human Development Services andthe Bureau of Maternal and Child Health andResource Management.

Despite the good efforts of a number ofsocial, educational, and health services withinthe state, native Hawaiian children are at risk

for a wide range of problems virtually frombirth. Hawaiian babies are the most at-riskgroup of the four major ethnic groups in thestate. Hawaiian children as a whole are over-represented in all of the categories associatedwith negative developmental outcomes. Only14% of Hawaiian 4-year-o!ds in the pre-schools passed a routine hearing screening.The health, education, and social problems ofHawaiian children are complex. Whatemerges is a picture of a major ethnic groupthat is under severe stress across the board.This is in direct contrast with what one sees ofHawaiian family's when they are able to func-tion ard nurture their children with supportsystems adequate to meet their needs. ThePREP program was designed to help fosterthese supports. Although the approachta rn phasiz ed in PREP was an educational one,the project sought the cooperation and activeinvolvement in health and social service agen-cies so that all three components could worktogether to provide a coordinated support sys-tem for families.

A cornerstone of the PREP model is a com-mitment to strong community involvement inplanning and implementing programs.Another important aspect of the project is theincorporation of cultural factors in programdesign. Traditionally, native Hawaiian childrengrow up in a loving and warm family environ-ment that encourages individual responsibilityto the welfare of the entire household. Child-rearing typically fosters early independenceand strong identification with the peer group,which often consists of extended family mem-bers around the same age. Family membersare close knit and draw upon one another forsupport in a wide range of areas. ThisO'hana, or family system, creates opportuni-ties for family members of all ages to worktogether and support each other in times of cri-sis as well as when things are going well.While this system is not universal in Hawaiianfamilies, it represents the stereotype many

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families hold as the ideal. Even though it mayadd further stress to the family system, it actsas a strong motivator to maintain bonds withinfamilies as a powerful force within the contem-porary Hawaiian culture.

The PREP program does not attempt tomirror all aspects of Hawaiian culture. Somecultural components are explicitly woven intothe model, while others naturally emerge fromthe interaction of the families with educatorswho are embedded within the culture them-selves. Patterns that are particularly importantin the program involve how adults interact,develop friendships and support each otherwithin the extended family system, and howHawaiian children learn information abouttheir social and cognitive world within thissame system. Families can begin to partici-pate in PREP as soon as the mother knowsshe is pregnant, and they can remain in theprogram until the child Pnters kindergarten.During pregnancy and with the child reachesthe age of 2, parents are involved in PREP'shome visiting component called Kupulani.Two- and 3-year-olds and their families partici-pate in traveling preschools, while 4-year-oldsattend center-based preschool classrooms.Since many families have more than one childin PREP, families may be involved in one ormore program components.

PREP's first goal is to help the familydeliver a healthy full-term infant. Thus, healthissues are emphasized early in pregnancy.The home visitor who sees each family weeklyencourages parents to become more effectiveconsumers of the services available within thecommunity. The home visitor who is Jsuallyfrom the community presents information in aculturally compatible way. Early home visitsmay be used to establis'. 'ftinders between thehome visitor and the family members. Throughinformal discussions, they discover commonfriendships, experiences, and overlaps inextended family membership. This process

legitimizes the home visitor's role within thefamily and provides an opportunity for her tobecome a trusted "auntie" who offers sugges-tions and advice.

Rather than adopting a didactic style, thehome visitor uses a "talk story approach,"interweaving information into the general ebband flow of the conversation. In this way, thehome visitor informally assesses the child'sdevelopment and passes the informationalong to the parents, preparing them for newstages in development and offering sugges-tion about how they can encourage new skills.

Activities during home visits before thebaby is born center around making a quilt. TheKupulani quilt is based on Hawaiian quiltswhich are a traditional Hawaiian art form andas such, represent a tie to the Hawaiian corn-munity.This concrete experience, the construc-tion of the quilt with four panels, is used toconvey information to the family about thedeveloping child. Each of the panels are col-ored in liquid embroidery by family membersand has a picture imprinted depicting familymembers interacting with a young baby. Byusing the panels on the quilt as a guide, theparents and the home visitor have an opportu-nity to disc ,s different ways babies receivestimulation and why each is important, and thehome visitor is able to offer practical tips onhealth and child-rearing issues. The quiltserves several functions: (a) It is the focus ofinteraction during several of the prenatal visits;(b) it serves as a welcoming blanket for theinfant; and (c) because it remains in the home,the quilt serves as a continuing reminder ofthe ideas it depicts. It also serves as an impor-tant part of the dissemination and recruitmenteffort, because parents in the program talkabout the quilt to other family members whothen also want to participate.

After the child is born, families move intothe second phase of the home visiting pro-

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gram. Each month of the baby's first year andevery month of the second year, the home visi-tor gives the family a t-shirt with a picture on itdepicting a baby at a correspondingdevelopmental stage. For example, the 4-month-old t-shirt shows a baby lying on its

The t-shirt is captioned, "I cansay Ooh. Can you?" This t-shirtprompts a discussion between thehome visitor and the family....

"M11back making eye contact with the mother, whois very close. The t-shirt is captioned, "I cansay Ooh. Can you?" This t-shirt prompts adiscussion between the home visitor and thefamily about early language development andhow parents can help foster this developmentby talking to their babies during such dailyroutines as diapering or bathing and mimick-ing the cooing sounds they make. Onemother, atter being introduced to this t-shirt,commented that she didn't know she was sup-posed to talk to her infant, since he couldn'ttalk back to her. Frequently, home visits occurin groups where two or three sisters who mayhave children at the same age will gettogether and visit with the home visitor in anextended family style. Home visits occur any-where that families may be living from aban-doned cars on beaches to modern apartmentsin downtown Honolulu.

The second phase of the program for tod-dlers is the traveling preschool program. Twomornings a week, a van pulls up to differentcommunities within the state to provide a trav-eling preschool experience for families withyoung children. The location may be a park, achurch parking lot, or a community recreationcenter. Parents and children help the travel-ing preschool teacher unload the van and setup the traveling preschool under a banyantree or some suitable shady area. There arefive or six learning centers that are set up

within the school, and materials are preparedahead for each center. Typically, 20 to 30 fam-ilies and children come to the program eachday who may range from infants to 4-year-oldchildren. The program emphasizes the use ofextended family members in their care-takingrole with children and encourages these fam-ily members to come to the traveling preschoolwith the child. The teachers role throughoutthe several hours that the school is in opera-tion is to circulate among the parents demon-strating ways that the inexpensively made toysand materials that are avaliable at each centercan be used. Parents and extended familymembers are encouraged to interact with theirchildren around the materials provided.

On any given week, there may be an artcenter set up where children make prints offishes or leaves of native plants. The bookmo-bile visits, and parents are encouraged to signout books to take home for the week to usewith their children. A toy lending library isavailable so that parents can borrow inexpen-sive toys and take them home and use themwith children. The emphasis is to provide awide range of experiences for families to thinkabout how they interact with their children in afun way. The other emphasis is on using inex-pensive materials found on the beach or in theparks as part of the experience. Thus, Kukuinuts are used for sorting tasks, and sea shellsmay be used to help children learn to count.

The traveling preschool also provides aperfect opportunity for public health nurses tovisit children in this relaxed setting and to con-duct well-baby checks on those children whoare attending that week. Typically, duringeach session, parents meet for a short timewhile the children are having a snack andjuice, and the teacher leads them in discus-sion on an issue of common interest. Duringthis parent time, the public health nurse maytalk to the parents about hearing problemswith children, the importance of immunization,

or where the well-baby clinics are conductedin that neighborhood. Alternately, a socialworker may come and talk with families aboutservices that are available, either free or atlittle cost.

The third component of this program is thepreschool for 4-year-old children. In manyways, it mirrors a typical 4-year-old preschoolwith the exception that it very strongly empha-sizes language production with young chil-dren. Recent tests of 4-year-olds in the PREPpreschool program suggests that over half ofthe children have chronic and longstandinghearing problems, which affects their ability touse productive language and to learn in aclassroom setting. Thus, a strong emphasishas developed in testing children and refer-ring children with chronic hearing problems tophysicians for continued follow up. Otheraspects of the preschool that suggest compo-nents of a Hawaiian culture include encour-agement of family members to be present inthe preschool classroom and to help in waysthat they feel comfortable with the teacher.Parents or older siblings or relatives areencouraged to come early and spend timereading to the children in comfortable andrelaxed settings that foster a nurturing attitudetowards books.

Two important components of the PREPprogram should be highlighted for the pur-poses of this workbook. First, each of theseprograms began as pilot a project within onecommunity and then expanded to other com-munities in nearby neighborhoods. Theexperience in expanding the home visitingcomponent to a second community is worthyof note. Program developers learned verysoon that success in one community meantlittle in developing the program in the secondcommunity. New contacts, new relationships,and new trust had to be developed with eachcomponent of program expansion.

A second lesson learned from the devel-opment of this program involves the impor-tance of community-based training for staff.Careful time was taken to nurture communityinvolvement in developing a training programfor staff when the program expanded from onesite to new sites. All of the home visiting pro-grams in Honolulu contributed to the trainingprogram. Community members were con-sulted in developing the curriculum and wereactively involved in defining the kinds of skillshome visitors needed to begin service to fami-lies. Much time was spent in the training pro-gram itself in helping new home visitors iden-tify their own cultural backgrounds andunderstand how their backgrounds wouldaffect their ability to work with Hawaiian fami-lies with young children.

ReferencesA series of technical reports are available

from the Director, Prekindergarten EducationalProgram, Kamehameha Schools, BishopEstate, Kapalama Heights, Honolulu, Hawaii,96817. These technical reports cover thedevelopment of curriculum materials, thedevelopment of various aspects of the pro-gram, the cultural aspects of program develop-ment, and training issues. A series of video-tapes have also been developed whichdescribe each component of the program andmay be obtained from the above address. Theprogram has also been described in the publi-cation by the Office of Human DevelopmentServices called Children Today, and can befound in the July-August 1988 issue of thatjournal.

CENTER FOR SUCCESSFULCHILD DEVELOPMENT(THE BEETHOVEN PROJECT)

The Cerler for Successful Child Develop-ment (The Beethoven Project, CSCD) repre-sents a major effort by private sources, the fed-eral and state governments and thecommunity to affect the educational, social,

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and health outcomes of entering kindergartenclasses of elementary schools serving theRobert Taylor Homes. All project participantsare African American. This project is locatedin the Robert Taylor Homes community on thesouth side of Chicago, which is a series of 28high-rise apartment buildings housing 20,000residents located between freeways within ableak inner-city environment with little or nosoftening touches surrounding them. Thecrime rate, drugs, and all the problems ofinner-city high-rise housing are exaggeratedwithin this community. In this context, TheBeethoven Project provides early interventionand family support services to families whosupport school success.

An attempt has been made to locate everypregnant woman regardless of age within thecatchment area of the Beethoven ElementarySchool. A medical clinic has been esta-blished within the program, and prenatal careis provided in-housfl. When children are born,home visiting services are provided to mothersin the program. These services involve a teamapproach to home visiting. In light of theincreased awareness of family needs, CSCDhas expanded to include additional support forthe home-based program. Home visits aremade by a team consisting of home visitorsand child development specialists. Home visi-tors continue to make their weekly home visitsto provide social support information and link-age to CSCD center-based services and otherapprcpriate community services. Theexpanded services, however, providebimonthly support by specialist who join themon the visits to provide major emphases onchild rearing early child development and caregiver infant interaction. The health specialistand social worker also serve as members ofthe team when their services are needed inthe home setting. A family drop-in center andinfant toddler day care center have also beenestablished within the center. Thus, a combi-nation of center-based and home-based pro-

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grams are available to the families participat-ing in the project. The home visitors primarilycome from the public housing developmentproject and have been trained to deliver homevisiting services to families within the commu-nity.

Outside agencies may characterize manyfamilies within this project as being withouthope. Stereotypes prevail in blaming familiesfor conditions caused by economic and socialneglect of this community. However, programstaff have had a unique opportunity to developtrusting relationships with participants in theprogram and have come to understand therange of ways families have been able to copewith the unreasonable societal pressuresinherent in these living conditions. The loca-tion of the project within the Robert TaylorHomes buildings has made the developmentof this relationship possible. By virtue of theirlocation staff experience some of the stressorsfamilies experience on a daily basis. Theywork with parents and the community toemphasize the positive aspects of what can bedone and the affirmation that every child has achance to make it.

An example of this attitude involves thecelebration which occurs annually to recog-nize the birth of children within the program forthat year. Rather than viewing the birth of anew child as another burden to the family andthe problems that are associated with it, theproject has created an atmosphere wherebabies are welcomed into the community, andthe community is charged with the responsibil-ity of providing community and social supportto the pargnts of that child.

As described by the leaders of the pro-gram, this ceremony has its roots in Africansocial systems in which a naming ceremonyoccurs for each child. The naming ceremony iscalled an "Adinto." Useni Perkins, an expert onAfrican American cultural celebrations and anauthor, designed the ceremony. In the tradi-

tional African society, each child is consideredto be the responsibility of the entire commu-nity. Although the child's parents provide thefoundation for the child's development, thecommunity reinforces this foundation throughits institutions, values, culture, and concern forthe child's welfare. The child becomes anextension of the community, and members ofthe community become the extended family ofthat child. Therefore, the naming of the child isextremely important. It allows the entire com-munity to celebrate the child's birth.

The naming ceremony within the Bee-thoven Project is an African/American adapta-tion of this traditional Ghanian "Adinto" cere-mony. It is a festive occasion and features arange of community talent such as poetry,drama, art, music, and food. All children whohave been born within the community withinthat year are presented to the community, andthe community is charged to actively supportfamilies of children. During the ceremony, thepresiding adult explains to the community thepurpose of the Adinto and talks with themabout their responsibility in helping children togrow and be nurtured. This explanation is fol-lowed by a reading of Langston Hughes°poem, "I've Known Rivers," to acknowledgethe community's relationship to mother Africa.After reading the poem, he calls on some ofthe elders for words of wisdom. After each ofthe elders have been given an opportunity tospeak, the presiding adult calls on the commu-nity to celebrate the birth of the newborn chil-dren from that year. Recognizing its impor-tance, the speech of the presiding adult iscaptured here in full.

CI CI CI"At this time, we will celebrate the new-

born children in our community. As a commu-nity, we recognize that these beautiful childrenare the seeds of our heritage, fruits of ourlabor, and the future of our people. We mustcare for them, we must protect them, we musteducate them, and we must love them. As a

community, k.fe must share these responsibili-ties. Will each parent please step forward withhis or her beautiful child." At this point, theparents step foiward with their children. "Wewelcome your beautiful child to our commu-nity. May he or she live to be strong, healthy,and wise." The parent then announces thename of the child. After each child's name isgiven, the presiding adult repeats the follow-ing words, "The community congratulates youon your children and pledge that we will helpthem grow to be strong, healthy, and wise."The presiding adult then presents each parentwith a gift from the community and recites thepoem "Hey Black Child." After the poem, thedrums beat again, and the parents take theirbabies back to their seats and receive con-gratulations from other members of the com-munity. A celebration then continues withmusic and food.

0 0 0Unlike the ceremonies and traditions that

new immigrants may bring to a country andcontinue there, this ceremony represents areaffirmation of culture that has struggled tomaintain its integrity in spite of efforts to dimin-ish and extinguish it by the dominant culture. Itis a reaffirmation of the strength within a com-munity if it works together to nurture and raisechildren successfully. It does not negate thevery serious social, economic, and politicalissues that stand as formidable barriers forchildren and families within this program tomake it within modern society. Nonetheless, itreaffirms the value of each child and providesan opportunity to celebrate the importance oftheir birth as he or she is introduced into thecommunity. It serves as the foundation forbuilding a sense of community in the midst ofsocial and physical isolation.

As with Me programs described in thissection, the CSCD staff and the community offamilies with the Robert Taylor Homes havelearned important lessons from each other asthe program has developed. First, the enor-

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mous heterogeniety of families with respect totheir goals, strengths and cultural values hadto be understood for progress to be made.Though community involvement solicited fromthe beginning, a partnership could onlydevelop as trust was nurtured by caring staffwilling to listen and learn. The reaction of staffand family participants to aspects of the pro-gram designed to reflect cultural values wasbeing individualized and was a function of thelearning histories of each person.

FAMILIES FACING THE FUMEFamilies Facing the Future (FFF) is a pro-

gram of a neighborhood community humanservice center in Pittsburgh, PA. This programpromotes positive development for children atrisk of developmental delay by encouragingfamilies to become involved in early interven-tion efforts. The service is concentrated inthree low-income neighborhoods and deliv-ered through weekly hume visits by parent-aides. The parent-aides are full-time employ-ees, indigenous to the targeted community;trained, supported, and supervised by a socialworker and child development specialist.

Associating status rather than stigma withservice use is a primary goal. The statuscomes from a culturally sensitive atmospherethat encourages learning and empowerment.The parent-aides recruit families by means ofa door-knocking campaign. Their approach isupbeat, fun, and supportive. They encour-aged families to choose to become involved.During the home visit, a collaborative partner-ship is formed between parent and parent-aide. These partners promote positive interac-tions in the parent/child relationship. Theyfacilitate developmental growth of the childthrough play, games, and celebrations. Also,they discuss parenting issues and techniques.In addition to the home visit, parent education/support groups and family field trips areoffered.

In many cases, the job of parent-aide rep-resents the first full-time permanent employ-ment these home visitors have experienced.Because they are of the community, the par-ent-aides represent hope. They convoyrespect for the community and understandingof cultural and ethnic values. The parent-aides are trained to recognize and use thestrengths, competencies, and skills of the fami-lies they serve. They also recognize the con-text of the family's life and can locate tangibleresources when needed.

Training/supervising/supportparent aides.

The preservice training program for par-ent-aides was designed and implemented bya group of community professionals and lead-ers who joinad together to form the NetworkTeam, a support system for Families Facingthe Future. The basic framework for the train-ing--a month-long intensive session--wasused as a mechanism for developing groupcohesiveness while preparing the parent-aides for working with families. More than 30individuals participated in the training as lec-turers and trainers. An honorarium of $50 forone-half day was paid for this service.

The amount of group identification engen-dered in participants alone was an invaluableresult of this experience. It was clear to thetrainees that they were a vital, in fact, the cen-tral factor of the program. Several aspects ofthe training program can be considered asinstrumental to its success:

1. The curriculum allowed for amplediscussion of concerns, ideas, andobservations.

2. The course director was upbeat andsupportive.

3. There was an underlying respect forthe integrity of the individual and

acknowledgement of the importance ofthe program and the rule of the parent-aides.

4. There was a sense of joint effort ratherthan a student/teacher atmosphere.

5. There were numerous occasions dur-ing the training period for the traineasto meet with and learn to know themembers of the Network Team.

6. The training program provided participants with exposure to role modelswhich were appropriate to their ownpotential.

The on-going training, supervision, andsupport for the parent-aides is provided in avariety of ways. On-going training, beyondteaching in weekly staff meetings, take placemonthly through paid or volunteer consultants,case conferences at Children's Hospital, orstaff designed review sessions. Weeklysupervision is conducted by the neighborhoodhealth center's social worker for case reviewand planning.

For additional support, the agency con-tracted with a community professional identi-fied by the parent-aides as one of their favorite1=INIE /11

This woman is a Ph.D who wasonce an indigenous worker and a homevisitor. She meets weekly with the par-ent-aides in a group for a confidentialsupport group.

trainers. This woman is a Ph.D who was oncean indigenous worker and a home visitor. Shemeets weekly with the parent-aides in a groupfor a confidential support group. This modelailows discussion of issues of major impor-tance including the difficulties of having theirfirst job and becoming paraprofessionals; diffi-

culties in dealing with the families on theircaseload within the community; and, the inter-action of their own family history with thefr abil-ity to wor!: with families in the program. Thisoverall model requires communication andcoordination by the professionals, but it pro-vides support and professional growth foi thehome visitors.

The training component of this projectwas emphasized to illustrate the need for cul-turally competent training and the communitybase of this effort. In addition, this modelendorses the principle that staff must have thecapacity and time to self-assess their owncultural values and relate them to their on-going work with families.

SOUTHEAST ASIAN DEVELOPPIEIITALDISABILITIES PREVEMION PROJECT

The Southeast Asian Development Disa-bilities Prevention Project (SEADD) is aSPRANS project awarded to a large commu-nity agency called the San Diego ImperialCounties Developmental Services Inc.SEADD is a separate project under theumbrella of the larger corporation and is sub-contracted to the Union of Pan Asian Commu-nities agency. As mentioned earlier, this is anexample of the kind of program which islocated within a community and operated bymembers of that community, but has a largermainstream organization as its administrativehead.

SEADD began out of a concern for theneeds of newly arrived immigrant families fromSoutheast Asia settling in the San DiegoCounty area whose children were at risk for orwho had developmental disabilities (ages 0-3). In large part, these families were not beingseen by the regular service providers, thoughit was evident from birth records and othercommunity knowledge that a high percentageof these children required services. Typical

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caseloads carried by a counselor in the SanDiego Regional Center were as high as 80and this made it very difficult for the case work-ers to provide adequate services to the newlyarrived immigrant families.

There are four immigrant groups servedby SEADD, each of which has its own lan-guage, cultule, and distinct problems. Theseinclude Cambodian, Vietnamese, Hmong, andLaotian families. The program employs fourbicultural/bilingual counselors who are fromthe same community that they serve. Thereceptionist/secretary speaks enough of eachof the four languages that she is able to greetfamilies when then call and refer them to theappropriate counselor. Each of the counse-lors is an immigrant and has experienced thesame hardships of refugee camps and dislo-cation/relocation of families in the program.The counselors help bridge the gap betweenthe services families need and the network ofservices that are available to them in the com-munity. In most cases, families do not speakEnglish, are recently immigrated, and carrywith them strong belief systems and culturalexperiences quite far apart from western medi-cine and practice. One of the counselors wasrecently interviewed and described his experi-ences with families this way:

LI LI LIMost of the referrals that I receive are from

the hospital. Other referrals are from family tofamily. By serving this family or that family, Ihelp a child with a special condition. So it iswithin the community that we go end try toexplain to new immigrants how we can helpthem. We tell them, "We are set up to workwith families with special needs children."

As an example, one of the children that Iworked with was microcephalic and also hadan infectious disease called CMB. His condi-tion was pretty bad, and we saw him at birth.Well, I got the referral in the hospital. The

While the child stayed in the hospi-tal, [the husband and the grandpar-ents], refused to visit the child...because they blamed the mother andthought that she did something bad tocause the condition.

.4Mifamily was already mad at one another andmad at the mother. The mother was about 16and the father was about 17. They were bothvery young, and they had extended family liv-ing with them in their home. They all blamedeach other, but particularly blamed the motherfor the child's condition. While the childstayed in the hospital, the extended familyrefused to visit the child. I mean, the husbandand the grandparents, because they blamedthe mother and thought that she did somethingbad to cause the condition.

So, when I got the referral and I went tothe home and I tried to see what was going onwith the family and they had already foughtwith each other about what the mother mighthave done. Maybe she had an affair withsome other man who had a disease, youknow, or maybe she had done somethingwrong on her side of the family in the pastgeneration and now it came back as punish-ment. The mother was very lonely and verysad, and she felt very guilty too. She was feel-ing guilty because everybody said it was herfault, so I tried to pull everybody back together,and the grandparents and the sisters and thehusband and all the other relatives.

I tried to explain to them about the condi-tion and what the doctor told me. I tried tomake sure that everybody understood. Iwanted to make sure they didn't blame themother. They did not believe me becausethey didn't see anything that could correct thecondition. I told them, yes, nothing could cor-rect the condition. The only thing they coulddo was what the doctor told them and continue

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to try to help their child. I continued to workwith them, and I started from there in gettingthem to accept their child and to accept whatthe doctor was saying about what they coulddo to help this baby. I spent many visits at thehospital and with the family getting them tounderstand what the doctor told me. After awhile, the family began to look at the baby andnot to make anybody at fault for the problem. Istill see the baby and the family and work withthe family in the school where the baby is now.

(QUID

The developmental outcomes of this caseare still very much in question, and it isunknown how far this child may develop. Thecounselor's intervention with the family helpedthem make contact with services they neededbut would not have used without intervention.He was also able to do this without question-ing or destroying the family's beliefs. Rather,their energy was refocused with respect towhat they could do in the present situation andnot lay blame on who was at fault. The familycontinues to need considerable support fromthe counselor, as it has over the 3 years of thisyoung child's life. No doubt the counselor willcontinue to work with this family and work astheir interpreter/translator in a very complexworld of social, health, and educational needprograms available to this young boy.

The strong bicultural/bilingual philosophywhich underlies this project is one of itsimportant teatures. Staff must be the bridgefor families from thbir natal culture to Westernsystems of care. To act in this capacity, staffmust have a firm understanding of the culturalsystems of families in the project and what ispossible within Western systems of care. Thewillingness to work within the family's goals isalso a critical element for SEADD staff. Theyare willing to take time needed to ensure thata family's goals are met.

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TR,ANSGENERATIONAL PROJECTThe Transgenerational Project sponsored

by Howard University's Child DevelopmentCenter is noteworthy as an example of a pro-gram that changed the kinds of services it pro-vided in order to be more responsive to theneeds of families. This project primarily pro-vides diagnostic services for young Black chil-dren referred to the clinic by local schools fordiagnostic testing for learning disabilities andother related educational problems. Over thecourse of testing children in an individual test-ing situation, the clinic staff were concernedthat no attempts were made to incorporateparent education/counseling within the pro-gram. As children would be tested, their par-ents were involved in simultaneous educationand counseling sessions. Parents were giventhe results of the child diagnostic study andshared these results with the school and otherinvolved agencies. Most of the families com-ing to the center were poor, inner-city Blackfamilies in Washington, DC. School had beena negative experience for many parents whofound it difficult to confront or interact withschool personnel. This tn.nsgenerationalcycle of strained school relationships had tobe redirected to ensure that the recommenda-tions developed by the clinic were carried out.

The goal of the Transgenerational Projectwas to maintain open lines of communicationbetween the family and child, health agency,and the school. They continued to acceptreferrals for screening of children, butaccepted the family rather than just the childfor services. Special sessions were devel-oped for family members to help them under-stand both what was going on in the testingprocedures and what they could do in helpingtheir son or daughter in school Counseling offamily members helped them feel a sense ofpartnership with respect to the school system.Family members were taught how to work withthe teachers and principals and with the IEPprocess. This networking effort helped to

ensure that recommendations which camefrom the clinic were systematically followedthrough in the classroom. Parents alsolearned ways that they could work with theirchildren at home to enhance their educationalprogress. As one mother said of the program:

0 0 0When I was in school, I hated school. I

tried to hide the fact that my daughter was hav-ing trouble in school. I tried to ignore it andmake it go away. The project has helped mesee that it can only go away if I go away, if I getinvohad. They helped me see ways that Icould talk to the teachers and help my daugh-ter learn more so that she won't be afraid ofschool when she graduates.

0 0 0EPICS

The next program to be discussed is theEPICS project in Bernalillo, New Mexico. Thisproject is part of Southwest CommunicationsResources Inc., a regional resource centerwhich has a larger mandate to serve familieswithin the community and county. The agencysponsors twc projects which specifically serveNative Americans including EPICS, a parenttraining and information project funded in partby the U.S. Bureau of Maternal and ChildHealth, and the U.S. Office of Special Educa-tion and Rehabilitative Services. This projectserves Native American families throughoutNew Mexico and provides technical assis-tance to other families and programs nation-ally. The second project is the Pueblo InfantParent Education Project (PIPE) which is alocal early intervention program which pro-vides direct services to the area. All commu-nity families are eligible for service in this pro-gram.

EPICS wHI be discussed in some detailbelow. It uses indigenous case workers towor% with Indian families whose children havedevelopmental disabilities to obtain the kindsof services which their children need. On a

31

parallel track, it works with professionalswithin the Indian Health Service local hospi-tals and clinics to help professionals under-stand the cultural values of Indian families andhow these values affect the services theyshould be providing. Thus, it very appropri-ately addresses both sides of the issue. Fami-lies understand that they can choose tradi-tional healing practices and those that areavailable under western medical system. Theyunderstand that they need not abandon oneapproach in order to use the other. On theother hand, professionals are encouraged tounderstand the perspective of families andtheir cultural heritages. Professionals areencouraged to understand the rights of par-ents in making decisions with respect to thetypes of care that their children should receive.EPIC's goal is to help create conditions where

Indian parents do not feel they have to choosebetween traditional practices and westernpractices. Agencies should work together withsufficient collaboration that parents feel com-fortable working within both systems and donot feel a conflict with respect to the best treat-ment for their children.

One important aspect of the Navajo cul-ture, for instance, is harmony with nature anda holistic approach to wellness. Families mayview medical and developmental problems asa result of disharmony within that natural sys-tem. These beliefs lead Navajo parents to adifferent set of interactions with the health sys-tem than mainstream or Anglo parents. First,problems may not be brought to the attentionof the physician or a nurse, since it is not seenas a medical issue. Only when a childreaches school age may a problem becomeapparent to the educational or medical sys-tem. Second, within the Navajo belief system,treatment involves regaining harmony throughtraditional means rather than developmentalor medical intervention. In fact, from the fam-ily's perspective, western intervention alonemay create more disharmony.

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Training for parents involves the work ofthree parent trainers, all of whom are parentsof special needs children. The makeup andthe interactional patterns in each parent train-ing meeting are governed by the preferred cul-tural style of the group in attendance. Forinstance, when training is done with Navajofamilies, two separate groups are held simul-taneously. One is in Navajo and the other is inEnglish. Families are free to choose whichgroups they would prefer to attend. In workingwith families from the Pueblos, however, onlyone croup is held and the talk and discussionare simultaneously translated in to the Nativelanguage. Thus, English speakers and non-English speakers are together. Within the cul-ture, separating the two groups would be inap-propriate and cause concern. The parenttrainers respect these differences in the waythey run parent training groups in differentcommunities.

As the EPICS project began, leaders ineach community were contacted to help par-ent trainers understand (a) the networks withinthose communities, (b) how informationshould be provided, and (c) how programsand meetings should be run to make it com-fortable for those who would attend. Commu-nity leaders were also important in helping tokeep track of ceremonies that may have baenscheduled within a community village and toensure that meetings were not scheduled intimes that would conflict with traditional tribalceremonies. The goal of the parent trainingmeetings was to help parents understand thesystems that were available for their childrenand help them become better consumers ofthe services that were available. One mother,who was also a parent trainer, described herexperiences this way:

0 0 0Within my family, there are family mem-

bers who are very traditional and others whoare very acculturated. If you live in a villagethat is highly traditional, then tradition will pre-

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cede above all else. You have to respect andbalance that between your family members aswell as other involved individuals. When ourchild was diagnosed as having a disability, wesought out the elders within the family foradvice and direction in the traditional treat-ment for our child. At the time, western medi-cine was not answering questions that wewere seeking about our child's disability. Wewere given several traditional ceremonies thatwe could follow to help his progress and tomend the disharmony that was caused. Aspokesperson was selected for us whoassisted us with the process of accessing thetraditional medicine. We were guided throughthis process step by step by the spokespersonand other appointed persons who were veryknowledgeable with what steps to follow andthe people to contact. In the use of traditionalceremonies, the entire family is often involvedin what western society would call the treat-ment program. So that the possibility of hav-ing the disharmony continue is eliminatedbecause everyone is treated. As for the cere-monies themselves, they are highly respected,and we seldom if ever talk about them, as theyare a sacred part of our lives that we choosenot to share with the outside. All we ask is thatyou continue to provide us with the samerespect we give others in their practices oftheir cultures.

Other families with whom I work have sim-ilar ceremonies. At one time or another, italways comes up, and it is always dealt withwhen it comes up. A lot of the times, thesefamilies do not let us know that they have hadthe ceremony. It is a very sacred part that wedont talk about, but it is important that they doknow that what ha-pens is a valuable coursefor us as Indians to utilize. It keeps everythinggoing in harmony for us, because if we are notin harmony, then it builds up. As far as tradi-tion goes, they try to go and get you to goahead and set everything back in harmony.

0 0 0

37

One goal of the parent training is to helpfamilies who are in conflict between the use ofwestern and traditional medicines feel com-fortable about the decisions they make withrespect to these two types of treatment for theirchildren. In some cases, this is directly dis-cussed, and in others it is handled in a moreindirect manner. Parent trainers havedescribed times when issues regarding tradi-tional ceremonies have come up in their train-ing meetings, and it has not been discussed indetail, because parents at the meeting werenot comfortable discussing it. Later, however,parents have called them and asked themhow they dealt with these issues themselves.This gave the parent trainers an opportunity todescribe their own experiences to families andhelp the family make a decision as to whatthey wanted to do outside of the context of thelarger group meetings.

The same parent trainer describes her dif-ficulties in working within the western medicaltradition in getting t!9 appropriate services forher child. Her child was hearing impaired, andshe knew that there was something wrongwith him, but did not know what the problemwas. Again, in her own words:

LI L3 IDI took him through a number of evalua-

tions with the doctors, but we never saw thesame doctor twice. It made it very difficult forme as I had to explain everything over againeach time. The audiologists also changed,making it additionally hard when I wanted orneeded input or confirmation on an evaluationthat the doctor was questioning. I had voicedmy concerns to my family before he was iden-tified as having a hearing loss, and we hadtraditional ceremonies done for him. After theywere done, there was progress, but it wasslow. I didn't know who else to ask for direc-tion or help in seeking western medicine, as Ihad been labeled an over-protective motherby the doctors and other medical staff. It was

so different from using traditional medicine,because I was assigned a spokesperson wholead me through the process of accessing tra-ditional medicine. The spokesperson acted asmy "case manager" in this process.

",s time passed, a new audiologist cameon board, and she was willing to listen to myconcerns. She disagreed with the labeling ofhim as being "just a boy and that boys areslow and he would eventually catch up." Shelistened to my descriptions of his actions athome and validated my feelings and con-cerns. She was willing to go along and testmy child in the way I suggested, which was tomove the console out of his line of vision andthen test him. I knew how visual my child wasand had in the past tried to get others to takethis into consideration, but up until this time,no one took my suggestions seriously. My sonwas tested once more using my suggestions.This time, the testing showed a definite loss ofhearing in both ears that were very differentfrom one another. Although I was satisfied infinally finding out that in fact he did have a dis-ability, I was also very angry because they hadnot taken me seriously and so much time hadlapsed, only adding to my child's delay. Mostparents coming from culturally diverse popula-tions are not comfortable dealing with westernservice providers. It is out of line in many cul-tures to be persistent. Many of them find it toooverwhelming and don't go back to get theservices they were seeking for their specialneeds child, and this I find very disheartening.

CI CI 0

The EPICS project has created severalvideotapes that are designed to point out thecultural differences between Indian familiesand the way most clinics are run. They helphealth care professionals understand the cul-tural patterns of Indian families and to interactin a more effective way by understandingsome of the reasons behind the communica-tion styles families use in the clinic. For exam-

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ple, some time is spent describing why manyfamily members may be present in an assess-ment or why it is important to get informationfrom both the grandparents or an auntie.

The PIPE project, a direct service earlyintervention program, works with families atthe level that is comfortable for the families.Some families may not be ready to acceptearly intervention efforts with their children, butmay be willing to accept financial assistanceto help pay for things that the family needs sothat the child's needs can be met in otherways. In this case, PIPE would assist the fam-ily in gaining access to financial assistanceand other resources. The focus of the earlyintervention project is to work with the entirefamily, building trust with that family and help-ing them understand the kinds of things theycan do to increase the developmental out-comes of their children. Sometimes it takesseveral years for families to come to this point.It is thra strength of this relationship and thelength of time over which it is built which helpsfamilies bridge the difference between tradi-tional views of disability and those of westernmedicine.

Both projects are making an impact onhealth care professionals and families. In thewords of the Executive Director of the project:

0 0 0Bridging the gap means looking at both

sides of it. It is not just training parents tounderstand the professionals, but taking thenext step and helping the professionals under-stand the parents' perspectives. It's not justthe health care professionals that have prob-lems. We talked about it in our own agency.We have early childhood staff that have comein new to our agency, and we have helpedprepare them when they have never workedon a reservation. We try to find people whoare able to do that and feel comfortable. Welook for ways to help them feel comfortable to

learn and not to feel that this is so foreign andalien to them that they just give up and walkout. You know, because that is what we areseeing--is a lot of turnover, and we don't wantto keep seeing turnover, but there is no train-ing that we know of now for health care profes-sionals, and that is one of our goals--to helpdevelop that training.

0 0 0The family-centered, community-based

focus of this program is the cornerstone of allof its efforts. It demonstrates the ability of pro-grams to continue to learn from the communi-ties they serve as the program becomesincreasingly culturally competent. Not onlymust families be treated uniquely, but so mustcommunities within cultural groups. In thissense, it shares this lesson with the PREP pro-gram first described. Program staff take timeto ask advice from community members andform a partnership with them. In this way, thecommunity is invited into the process ofdesigning a program to meet the needs of itsmembers.

This program also demonstrates effectivemethods for helping famlies to feel comforta-ble using both their cultural and the Westernsystems of care.

THE AVANCE FAMILY SUPPORT ANTIEDUCATION PROGRAM

The Avance Family Support and Educa-tion Program, which began in 1973, is a non-profit organization whose mission is tostrengthen the family unit, to enhance parent-ing skills which nurture the optimal develop-ment of children; to promote educational suc-cess; and to foster the personal and economicdevelopment of parents.

Avance strives to accomplish its missionthrough providing support and education tolow-income Hispanic parents and their young

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children in five communities in San Antonioand Houston, Texas. Avance believes theintervention to the family must begin in thehome, be community-based, be comprehen-sive in scope, be preventive in nature, havechildren (0 to 3) as the entry point, and mustprovide sequential services to child and par-ent.

Its core program is the parenting educa-tion program where mothers and fathers ofchildren under 3 years of age attend a 9-month, 3-hour weekly program to improvetheir capacity to become more effective par-ents and teachers of their young children. Thefirst hour is devoted to making educationaltoys; the second hour to lectures and culturallyrelevant class discussions relating to childgrowth and development; and the third hour isused to familiarize parents with the varioussocial services in the community. One of thetoys the mothers make is a mobile with "El Ojode Dios" (the eye of God) design that is foundin many homes to have God protect our younginfants. The class discussions are divided by

One of the toys the mothers make Isa mobile with "El Ojo de Dios" (the eyeof God) design that is found in manyhomes to have God protect our younginfants.

the parent's proficiency with English. Non-English speaking parents must have a bilin-gual teacher. In other classes, Black andAnglo individuals are the teachers. Eventhough they are not Hispanic, they are sensi-tive and very familiar with the Hispanic culture.

Avance brings existing under-utilizedsocial, educational, economic, and mental-health services to the families and makesthese systems work for them. While the par-ents attend the parenting classes, their pre-school children participate in Avance's Day

Care Center. Parents who attend class on adifferent cily volunteer to care for the children.Transportation to and from the Center is pro-vided.

In addition to the center-based compo-nent, the Avance staff visits the mother at herhome twice a month to record and to video-tape her and her child at play with a toy thatthe mother made at the Center. The homevisit serves as an opportunity for private, one-to-one conversation on problems the mothersmight be facing and provides a forum for feed-back on the progress of both parents andchild.

Avance offers numerous family trips to thelibrary, zoo, Sea World, rodeo and circus, andcelebrates holidays with a Halloween parade,Thanksgiving dinner, Christmas party, and anEaster picnic. At the Easter picnic, the moth-ers and children participate in an Easter egghunt--for the adults, the eggs are Cascarones(colored egg shells filled with confetti) that themothers crack on each other. The childrenparticipate in breaking the Pinata. The fathersattend camping trips with their children, makekites, participate in the Avance Boy Scouts, aswell as attend their parenting classes. TheHispanic father holds a high position in the tra-ditional Hispanic family. One cannot leave thefather out of se/vices to the families. One-to-one counseling and support is also providedto the fathers.

At the end of the 9-month program, theparents and children participate in a beautifulformal graduation ceremony at a local univer-sity where the parent(s) receive a certificate,and their children, dressed in cap and gown,receive a reading book. Mariachi music playsas the families proceed to the reception whereMexican pastry is served.

Of the 100 employees, 80 percent aregraduates of Avance who reside in the same

354 0

communities, speak their language, andunderstand their culture and their problems.The Executive Director, Gloria Rodriguez, andthe two associate Directors, Carmen P. Cortezand Mercedes Perez de Colon, are from thesame poor communities and after receivingtheir education returned to help the commu-nity. The staff are hired based on their sensi-tivity, compassion, and willingness to learn.They serve as role models for others in thecommunity.

The guiding principle that is used through-out the year, and a vital programmatic ele-ment, is that the parent be treated with thegreatest respect, and made to feel extremelyimportant and welcomed. Many parents didnot receive love and nurturing as children andAvance is filling the void. The parents immedi-ately establish a rapport with the staff and theythen become receptive to services.

By coming together as a group on aweekly basis for nine months,sharing commonconcerns and joyous moments, the parentsform close mutual friendships that continue togrow beyond the program. This importantsupport system recreates a sense of commu-nity where neighbor helps neighbor with childcare, protecting each others homes, or justbeing around whenever needed.

The core program gets to the soul of theperson. They begin to trust and to believe inthemselves. They go from a state of hopelessdepression and despair to one of hope andmotivation. They begin to set goals for them-selves and for their children. They begin tofeel a sense of power that their quality of lifeand their communities can change.

After completing the Avance ParentingProgram, the parents are ready to enter PhaseII, which is the Adult Literacy Program. Par-ents attend English classes, G.E.D. classesand college courses. Eighty percent of theparents had dropped out of school with a

mean educational level of the eighth grade.Hundreds of parents have obtained their highschool diploma, 10 have completed or are justabout to complete their Associates degree,and one has become a school teacher. Likethe parenting program, transportation and daycare are essential support services providedto the parents. Parents who have obtainedtheir G.E.D. or completed college courses arealso recognized at the Avance graduation cer-emonies. This motivates other parents to con-tinue their own education.

Phase III is job training and job place-ment. Avance has a full-time counselor assist-ing the parents in obtaining and maintainingemployment. One can find women and menwho were once on welfare employed asnurses aides, bus drivers with the city's transitsystem, in the police department as switchboard operators, in banks, as teacher's aides,etc. Avance recently had a ceremony wheresome of these parents were recognized, againreinforcing positive behavior and promotingsocial learning.

With employment, the families' quality oflife is improved, and many parents leave thehousing project (which was originallydesigned to be temporary) to rent or buy theirhomes. Some decide to stay and becomeleaders of the Resident Association or thelocal schools.

The children also have their own contin-uum of development. Many go from theparenting program to a Head Start program.Avance just re-established the tutoring pro-gram where older children assist youngerones with learning basic skills and concepts.Avance acquired 10 computers that will beused in the Tutoring Program. With a strongearly childhood foundation, and support andassistance provided from the parents, theAvance children have a better opportunity ofstaying in school and achieving academicsuccess. As the children are ready to gradu-

36 41

ate, Avance works with the local institutions ofhigher learning to get them scholarships oroffers scholarships to the parents' children toget them into college. Two cases in pointare Peggy Cortez, who, like her mother,obtained an Associates degree; or SandraGarcia, who, like her mother, wants to becomea school teacher. All four women were onceon welfare.

Avance serves over 3,000 mothers,fathers, and children. It has numerous otherprograms such as providing components ofthe comprehensive community-based modelin the schools. Avance recently received a 4-year Even Start contract through the Depart-ment of Education to provide parentingclasses and home visits in eight schools.

Avance also recently received a 5-yearComprehensive Child Development Program(CCDP) grant from ACYF. Avance will workwith 120 low-income families in two housingprojects, when the mother is pregnant, andsupport the family comprehensively for fiveyears. The objective of the program is that atthe end of five years, the target child will beready to meet with academic success, and theparents will become productive, contributingmembers of society.

Avance also has a program serving refer-rals from Protective Services on Child Abuseand Neglect, and it received a three-and-a-half-year grant from the Carnagie Corporationof New York to evaluate the effectiveness ofthe program model. Preliminary data demon-strates that Avance had a significant impact onthe home environment and on parent-childinteractions.

Avance gets its funding from varioussources, including the City of San Antonio,United Way, State and Federal government,foundations (Carnagie, Mailman, Hazen), cor-porations (Kraft-General Foods, who provided

the funds to replicate Avance from San Anto-nio to Houston, Texas, and Hasbro, Arco,UPS) and others. Its budget has grown fromthe $50,000 originally provided by the ZaleFoundation to $2,000,000.

37 4 2

REFERENCES

Anderson, P. (1989). Serving culturallydiverse families of infants and toddlers withdisabilities. Washington, DC: National Center for Clin-ical Infant Programs.

Bronfenbrenner, U. (1987). Ecology of the familyas a contest for human development: Research perspec-tives. Developmental Psychology, 22(6), 723-742.

Cole, L. (in press). Issues in multicultural profes-sional education. American Journal of Speechand Hearing.

Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs,M. R. (1989). Towards a culturally competentsystem of care. Washington, DC: CASSP TechnicalAssistance Center, Georgetown University Child Devel-opment Center.

Gottlieb, B.H. (1983). Social support strate-gies: Guidelines for mental health practice.Beverly Hills, CA: Sage Publications, Inc.

Hanson, J.J., 1 ynch, E.W. & Wayman, K.I. (1990).Honoring the cultural diversity of families when gatheringdata. Topics in Early Childhood Special Educa-tion, 10(1), 112-131.

Jordan, C. (1985). Translating culture: From eth-nographic information to education program. Anthro-pology and Education Quarterly 16(2), 106-123.

Koop, C. E. (1987). Surgeon general'sreport: Children with special health careneeds. Washington, DC: Department of Health andHuman Services.

Levine, M., & Levine, A. (1970). A social his-tory of helping services: Clinic, court, school,and community. New York: Appleton-Century-Crofts.

McAdoo, H. P. (1982). Derlographic trends forpeople of color. Social Work, 27,15-23.

Yumori, W.C., & Loos, G.P. (1985). The per-ceived service needs of pregnant and parent-

Ing teens and adults on the Walanae Coast.Honolulu, HI: Kamehameha Schools/Bishop Estate.

Roberts, R. N. (1988). Family support in thehome: Home visiting and public law 99-457.Washington, DC: Association for the Care of Children'sHealth.

Shelton, T. L., Jeppson, E. S., & Johnson, B. H.(1987). Family-centered care for children withspecial health care needs. Washington, DC: Asso-ciation for the Care of Children's Health.

Tharp, R.G. & Gallimore, R. (1984). Product andprocess in applied developmental research: Educationand the children of a minority. In M.E. Lamb, A.L. Brow &B. Rogoff (Eds.), Advances in developmental psy-chology, Vol.III. Hillsdale, NJ: Erlbaum Associates.

Wasik, B.H., Bryant, D., & Lyons, P. (1990) Homevisiting. New York: Sage Press.

FOOTNOTES

1 The reader is referred to two excellent video-tapes produced by Southwest CommunicationsResources, Inc. entitled "Listen With Respect" and"Finding the Balance." The videotapes are designed tohelp professionals working with Indian families to gain aperspective on cultural issues which interact with west-ern medicine. For more information on the videotapes,contact:

Randi MalachEPICS ProjectP.O. Box 788

Bernalillo, NM 87004

2The Rainbow Series is published by GeorgetownUniversity Child Development Center, National Centerfor Networking Community-Based Series. For furtherinformation, contact the series editor.

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