striving for behavioral health equity in colorado...striving for behavioral health equity in...

Striving for Behavioral Health Equity in

Colorado:

Research on Identification of Mental Health Needs Among

Latino Youth, Solutions for Reducing Disparities and Using the

DSM-5 Cultural Formation Interview and CLAS Standards to

Increase Provider Cultural Competency

March 6, 2018

Annual Research and Policy Conference:

Presenters

Claudia Zundel, MSW, Director of Workforce Development and Innovation,

Colorado Office of Behavioral Health, Chair

Ashley Brock-Baca, PhD, Trauma Responsive Service Array Developer,

Colorado Office of Behavioral Health, Discussant

Omar Gudino, PhD, Assistant Professor, Department of Psychology,

University of Denver “ Caregiver and Provider Perceptions of Internalizing

Mental Health Need in Latino Youth”

Allison Stiles, MA Department of Psychology, University of Denver,

“Solutions to Reducing Mental Health Service Disparities among Latino

Youth.”

Mita Johnson, Ed.D, LPC, LAC, Evergreen Consulting Group, LLC, “Using

the DSM-5 Cultural Formulation Interview and the CLAS Standards to

Improve Behavioral Health Provider Cultural Competency”

2

Race and Ethnicity

3

0 20 40 60 80 100

Native American

Native Pacific Islander

Asian

Black

Hispanic/Latino

White

Counts of SOC population

0 5000 10000 15000 20000 25000 30000 35000

Native American

Native Pacific Islander

Asian

Black

Hispanic/Latino

White

Counts of Mental Health population

Count - number of members in ethno-racial group - not distinct

Children and Youth ages 0-25

https://statisticalatlas.com/state/Colorado/Race-and-Ethnicity

Race and Ethnicity by Age and County

4

https://statisticalatlas.com/state/Colorado/Race-and-Ethnicity

Race and Ethnicity by County

Caregiver and Provider Perceptions of Internalizing Mental Health Need in Latino Youth: A Mixed-Methods Approach

Omar G. Gudiño, PhD, ABPP

Acknowledgments & Disclosures

Funding:

Disclosures: No conflicts of interest to disclose

Partners: Claudia Zundel, MSW & Jane Flournoy, MA

Unmet Mental Health Needs Latino youth disparities

Ethnic disparities by problem-type internalizing vs. externalizing

Explanations for DisparitiesAttitudes and values

Forces within and outside of family

Practical barriers

Recognition of MH Need Identification of need service use

Role of adult gatekeepers

Internalizing problems Impairment

Need for services

Disconnect between ratings of impairment and need for services in Latino youth

Chavez et al., 2010

Present Study

How do adult gatekeepers perceive internalizing vs. externalizing problems in Latino youth?

What influences perception of mental health need for Latino children and adolescents?

Leveraging Stakeholder Perspectives

Community mental health centers and organizations in 3 counties in Colorado

Latino families in services (N=16)

Latino families not in services (N=23)

Providers/Managers (N=51)

Measures

Experimental vignettes (Chavez et al., 2010) Internalizing vs. Externalizing

Moderate severity

Ratings of seriousness, impairment, and need for services (1-10 scale)

Semi-structured focus group (~1 hr)How do Latino families identify mental health needs?

Discussion about vignettes

Procedure

Meal, questionnaires, focus group

Audio recording of focus group

$25 incentive, family meals, and childcare

Data Analysis Nvivo for transcription and coding Directed content analysis

Mixed ANOVA in SPSS to analyze vignette ratings

Factors Influencing Perceptions of Need

Total Across Groups

(ref: 646)

External Sources 33.13%

School personnel 13.78%

Physical health providers 7.59%

Extended family-friends-neighbors-community 5.73%

Other 2.01%

Government 2.01%

Parents 1.39%

Clergy 0.62%

Not recognizing problems 12.08%

Other Norms 7.74%

Cultural Norms 3.10%

Gender 1.24%

Explanatory Models 3.56%

Other Norms 1.55%

Cultural Norms 1.08%

Gender 0.93%

Perceptions of Seriousness

0

1

2

3

4

5

6

7

8

9

10

Externalizing Internalizing

Providers Families in Services Families not in Services

Perceptions of Family Impairment

0

1

2

3

4

5

6

7

8

9

10



Perceptions of Peer Impairment

0

1

2

3

4

5

6

7

8

9

10



Perceptions of Need for MHS

0

1

2

3

4

5

6

7

8

9

10



Factors Influencing Perceptions of Need

Total Across Groups

(ref: 646)

Providers and Managers

(ref: 454)

Fam in Services

(ref: 126)

Fam Not In Services

(ref: 66)

Aspects of MH Problem 51.23% 28.48% 15.48% 7.27%

Type of problem 24.30% 13.31% 6.97% 4.02%

Internalizing 6.35% 2.48% 2.79% 1.08%

Unclear Symptoms 6.19% 3.25% 1.39% 1.55%

Externalizing 6.19% 2.47% 2.48% 1.24%

Problem-Types Contrast 5.57% 5.11% 0.31% 0.15%

Impairment-Distress 10.68% 8.36% 1.39% 0.93%

School Impacted 4.02% 3.41% 0.46% 0.15%

Family Impacted 6.66% 4.95% 0.93% 0.78%

Severity 7.89% 4.33% 2.79% 0.77%

Related to Self-Harm 5.57% 3.56% 1.55% 0.46%

Precipitating Stressors 8.36% 2.48% 4.33% 1.55%

Summary of ThemesTheme/Subtheme Examples

Type of problem Aspect of the presentation influences perceptions of need

Internalizing Anxiety, depression, isolation, withdrawal

“she feels worthless, she won't talk to friends, she don't feel like eating”

Unclear Symptoms Not talking to parents

“she started wearing black and she started listening to like bad music “

Externalizing Anger, gang involvement, substance use, fights

“he thinks he can do whatever he wants when he wants. I have no say so. I say you can't go anywhere, he takes off out the door”

Problem-Types Contrast Specific mention of internalizing vs. externalizing in determining need

“I see a large focus on behaviors more so than on possible underlying causes. He's not paying attention in school, or he's disobeying parents, or he's yelling more than maybe there's some anxiety”

Summary of Themes

Theme/Subtheme Example

Impairment-Distress Impact of problem on someone or something influences perception of problem

School School functioning; attendance; teachers concerned about student

“we thought it would pass, but now they’re getting F’s”“…school district was like, ‘we're not going to allow him to come here anymore unless he's able to be controlled’”

Family Difficulties getting along with family; family conflict

“not spending time with family feels disrespectful”“parents feel overwhelmed”

Summary of Themes

Theme/Subtheme Example

Severity Problem has gotten very bad; worsening over time

“…write it off until maybe it got so severe that she wouldn't get out of bed or some things like that”

Related to Self-

HarmSpecific mention of self-harm, suicidal ideation, or suicide attempt

“Until they start cutting or are hospitalized or something”

Precipitating Stressors Parent is deported; traumatic event; divorce

“he went through some really tragic stuff about a year and a half ago that had to do with his father and stuff so then that's when I decided he needs to get services”

Conclusion

QUANTITATIVE

Families: Externalizing vignette ↑ Serious

↑ Family and peer impairment

Providers: Internalizing vignette ↑ Serious

↑ Need for MHS

QUALITATIVE

Factors influencing perceptions of need Cultural or gender norms

External sources

Type of problem

Impact on family or school

Severity and self-harm

Precipitating stressors

Implications for Research, Policy, & Practice Increased understanding of how children with mental health need are connected to MHS Identification of needs in broader context influencing service use

Explicit focus on how families seeking services sought them

Education on children’s mental health need (Re)Defining need

Identification of youth distress and impairment

Recognition that adults outside of family may identify need

Emphasis on internalizing problems at moderate levels

Early focus on access and engagement Explanatory models

Solutions to Reducing Mental

Health Service Disparities

among Latino YouthAllison Stiles, MA, Thania Galvan, MA, &

Omar Gudiño, PhD, ABPP

Annual Research & Policy Conference on Child,

Adolescent, and Young Adult Behavioral Health

March 4-7, 2018 | Tampa, FL

Mental Health Service Disparities

• 1 in 5 youth with mental health needs in the US receive

services (Kataoka, Zhang, & Well, 2002)

• 88% of Hispanic children in the US with mental health

needs do not receive treatment (Kataoka, Zhang, & Well, 2002)

• Despite decades of research, barriers persist

• Solutions to treatment barriers typically inferred

• Broad, rather than specific, solutions

• Consideration of a single perspective

Prior Approaches to Solving Disparities

• Adoption of a more comprehensive approach

• Direct investigation of solutions to service use

disparities across multiple perspectives

• Examination of similarities and differences among

stakeholder viewpoints

The Current Study

Participants • Recruited from mental health centers and organizations across 3 counties in Colorado

• Latino families IN services (N = 16)

• Latino families NOT in services (N = 23)

• Service providers & agency managers (N=51)

Measures/ Procedure

• Semi-Structured Focus Groups

• Demographic form

Data Analysis • Qualitative content analysis of focus group data

Methods

1) Overall themes and subthemes

2) Convergence and divergence among stakeholder perspectives

Results: Overview

Themes and Subthemes

Educational Outreach

Way to Provide Educational Outreach

Information Re: MH Problems & Services

• “services announced via the radio or television” or “pamphlets in the office with doubts you might have…”

• “…give more information about where to apply, how to apply, who to apply”

Integrated Systems

School Systems

Medical Providers/Primary Care System

Other External Systems

• “schools can have a psychiatrist that I know as a mother, that my children know…”

• “collaboration and integration between everybody…which means your education, your judicial, community, everything”

Improving Access To Services

Family Level Practical Solutions

Agency Level Practical Solutions

Multi-Systemic Practical Solutions

• “…services need to be open until late or on Saturdays so that people can receive help”

• “the state can make it available [assuming that all these children have medical aid] so that these services are covered”

Provider/Service Changes

Skill Building

Diversify Workforce Composition

• “…if they know that Latinos go there, they should have a receptionist that speaks Spanish”

• “more providers that speak Spanish and look like them”

Caregiver Support

Empathy for Caregivers

Self-Advocacy/Empowerment

• “what really helped me, in my heart, was when she [therapist] said, “I’m here to support you”

• “education for people about their rights”

Reduce Stigma/Fear • “…destigmatize seeking mental health services”

Themes and Subthemes Examples




• “services announced via the radio or television” or “pamphlets in the office with doubts you might have…”

• “…give more information about where to apply, how to apply, who to apply to”

Integrated Systems

School Systems



• “schools can have a psychiatrist that I know as a mother, that my children know…”

• “collaboration and integration between everybody…which means your education, your judicial, community, everything”





• “…services need to be open until late or on Saturdays so that people can receive help”

• “the state can make it available [assuming that all these children have medical aid] so that these services are covered”


Skill Building


• “…if they know that Latinos go there, they should have a receptionist that speaks Spanish”

• “more providers that speak Spanish and look like them”

Caregiver Support



• “what really helped me, in my heart, was when she [therapist] said, “I’m here to support you”

• “education for people about their rights”

Reduce Stigma/Fear • “…destigmatize seeking mental health services”

Themes and SubthemesAcross Groups(refs: 152)

Families in Services

(refs: 31)

Families Not in Services

(refs: 44)

Providers & Managers

(refs: 77)




Integrated Systems

School Systems








Skill Building


Caregiver Support



Reduce Stigma/Fear

Themes and SubthemesAcross Groups(refs: 152)

Families in Services

(refs: 31)

Families Not in Services

(refs: 44)

Providers & Managers

(refs: 77)




26.97%

17.76%

9.21%

9.21%

4.61%

4.61%

14.47%

12.50%

1.97%

3.29%

0.66%

2.63%

Integrated Systems

School Systems



23.03%

16.45%

1.97%

4.61%

-

-

-

-

8.55%

7.89%

0.66%

-

14.47%

8.55%

1.32%

4.61%





21.07%

11.84%

4.61%

4.61%

4.61%

1.32%

1.97%

1.32%

3.29%

1.97%

-

1.32%

13.16%

8.55%

2.63%

1.97%


Skill Building


15.79%

11.84%

3.95%

2.63%

2.63%

-

0.66%

0.66%

-

12.50%

8.55%

3.95%

Caregiver Support



7.24%

1.97%

5.26%

3.29%

1.32%

1.97%

-

-

-

3.95%

0.66%

3.29%

Reduce Stigma/Fear 5.92% 0.66% 1.97% 3.29%

• Direct investigation of solutions

• Bottom-up approach generates novel information

• Yields specific, actionable solutions

• Integration of multiple perspectives

• Incorporates range of solutions

• Understand priorities of various stakeholders

• Holistic approach to solving disparities

• Family-level interventions

• Provider/agency-level interventions

• System-level interventions

Implications for Research & Policy

Acknowledgements

University of Denver

• Omar Gudiño, PhD, ABPP

• Maria Islas-Lopez, PhD

• Skyler Leonard, MA

• Allison Stiles, MA

• Thania Galvan, MA

Office of Behavioral Health, Department of Human Services

• Claudia Zundel, MSW

• Jane Flournoy, MA

Funding

• Center for Community Engagement & Service Learning

For additional questions, please email: [email protected]

PROMOTING CLAS STANDARDSUsing DSM-5

Mita M Johnson, Ed.D & Deborah Ward-White

SCOPE OF WORKTrainings: State of Colorado

37

Deborah: CMECC: Colorado Multi Ethnic Cultural Consortium

Mita: Educator/Trainer/Clinician/Clinical Supervisor

Scope of Work: DSM-5/Cultural Formulation Interview + CLAS

Standards

Development of Training Module and Handouts

Delivery of Trainings: Grand Junction, Boulder, Pueblo, Denver,

Gunnison

Delivery of Training-of-Trainers

WHAT WE LEARNEDTrainings: What worked? What were the surprises?

38

Rural versus Urban Providers

Clinical vs. Administrative vs. Intake Staff

Funding or lack of funding: budgets and grant applications

Funding sources – evidence of integration of assessment and

CLAS Standards

Sound business practices and potential liabilities

Need for ongoing training and professional development

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