Adapting Evidence-Based Practices to Meet the Mental Health Needs of Immigrant and Refugee Communities Olga Acosta Price, George Washington University Mark Sander, MN Public Schools/Hennepin County Joshua Kaufman, LA Unified School District

Presenter Disclosures There are no financial interests to disclose 13th Annual Conference on Advancing School Mental Health

Evidence-Based Draws on theory Draws on theory Undergone scientific evaluation Undergone scientific evaluation “…programs or practices that effectively integrate the best research evidence with clinical expertise, cultural competence and the values of the persons receiving the services.” Oregon Addiction and Mental Health Division, 2007

Implementation of EBP Must include: Must include: Assessment of the feasibility of particular approaches Decisions about the quality of implementation efforts Concerns of fidelity Context Compliance Competence Determinations of school, organization, and community readiness

What is different now? Dramatically changing demographics In 2000, over 31 million individuals in the US were foreign-born (an increase of 57% since 1990) In 2000, over 31 million individuals in the US were foreign-born (an increase of 57% since 1990) According to the 2000 Census, 1 of every 5 children in the US is an immigrant or child of immigrants According to the 2000 Census, 1 of every 5 children in the US is an immigrant or child of immigrants Over 2 million refugees have resettled in the US in the past 30 years (large number being under 18 years old) Over 2 million refugees have resettled in the US in the past 30 years (large number being under 18 years old) 19% of children 5-17 speak a foreign language at home and 5% of all children have difficulty speaking English 19% of children 5-17 speak a foreign language at home and 5% of all children have difficulty speaking English

Cultural Competence How do we know that our constructs around mental health mean the same thing to our clients? How do we know that our constructs around mental health mean the same thing to our clients? Are we sure all aspects of service delivery are language accessible? Are we sure all aspects of service delivery are language accessible? Are our evidence-based practices really appropriate for the families and children from other countries of origin? Are our evidence-based practices really appropriate for the families and children from other countries of origin? What adaptations are necessary to make sure our treatment programs are effective? What adaptations are necessary to make sure our treatment programs are effective?

Robert Wood Johnson Foundation Caring Across Communities Program 15 grantees serving an immigrant or refugee- dense community 15 grantees serving an immigrant or refugee- dense community Building on the combined strengths of a community partnership Building on the combined strengths of a community partnership Utilizing a school base Utilizing a school base Reducing barriers to care created by language and cultural difference Reducing barriers to care created by language and cultural difference

Case Examples Involving the community in the adaptation process to ensure cultural competence Minneapolis Public School District Minneapolis Public School District Building Cultural Connections and Competence in School Based Mental Health Building Cultural Connections and Competence in School Based Mental Health LA Unified School District LA Unified School District Bienestar: Trauma Services for Immigrant Students Bienestar: Trauma Services for Immigrant Students

Building Cultural Connections and Competence in Building Cultural Connections and Competence in School-Based Mental Health Mark Sander, PsyD, LP and Minneapolis Robert Wood Johnson Partners

Partners Minneapolis Public Schools Minneapolis Public Schools Jim Johnson Jim Johnson Hennepin County, Children’s Mental Health Hennepin County, Children’s Mental Health Jamie Halpern Jamie Halpern The Mental Health Collective The Mental Health Collective Martha Olsen Martha Olsen La Familia Guidance Center La Familia Guidance Center Roberto Avina Roberto Avina African Aid African Aid Karim Behi Karim Behi Hennepin County - Office of Multicultural Services Hennepin County - Office of Multicultural Services Minneapolis Public School – Family Liaisons Minneapolis Public School – Family Liaisons University of Minnesota – Dr. Abigail Gewirtz University of Minnesota – Dr. Abigail Gewirtz “Support for this project was provided by a grant from Caring Across Communities, a national program of the Robert Wood Johnson Foundation.”

Demographics Somali in MN - unofficial est. 10,000-70,000; 2000 Census – 11,164 in MN (7,316 in HC) Somali in MN - unofficial est. 10,000-70,000; 2000 Census – 11,164 in MN (7,316 in HC) Oromo – 7,500 in MN Oromo – 7,500 in MN Latino – 175,000 in 2005; 76,981 in Minneapolis/St Paul; MN Latino population is relatively young: 1 in 3 is under 18; 1 in 4 Minnesotans overall Latino – 175,000 in 2005; 76,981 in Minneapolis/St Paul; MN Latino population is relatively young: 1 in 3 is under 18; 1 in 4 Minnesotans overall Minneapolis Public Schools Minneapolis Public Schools 76% Students of Color 76% Students of Color 26% English Language Learners 26% English Language Learners Large African immigrant population Large African immigrant population Largest Somali and Oromo communities in the nation Largest Somali and Oromo communities in the nation Growing Spanish speaking population Growing Spanish speaking population

Cultural Competence and Adaptation Delivering usual care and/or EBPs might not work for immigrants and refugees Delivering usual care and/or EBPs might not work for immigrants and refugees Need for cultural connections to inform adaptations Need for cultural connections to inform adaptations How do we know that our constructs around mental health mean the same thing to our clients? How do we know that our constructs around mental health mean the same thing to our clients?

Building Cultural Competence: Cultural Knowledge To increase our knowledge of the community, we are: Involving spiritual leaders from the African Community Involving spiritual leaders from the African Community Involving identified helpers from the Latino and African Communities (e.g., teacher assistants, other service providers, and community advocates) Involving identified helpers from the Latino and African Communities (e.g., teacher assistants, other service providers, and community advocates) Involving parents from the Latino and African Communities. Involving parents from the Latino and African Communities.

Identifying an EBP Having input from numerous informants Having input from numerous informants Mental Health Professionals with experience working with target populations Mental Health Professionals with experience working with target populations Community Workers with experience working with target populations (African Aid and Office Multicultural Services) Community Workers with experience working with target populations (African Aid and Office Multicultural Services) University Researcher (developer of EBP) University Researcher (developer of EBP) Mental Health Supervisors Mental Health Supervisors Identifying need for both population and clinicians gap in experience Identifying need for both population and clinicians gap in experience Identified: Trauma and parent-child interaction (relationship) Identified: Trauma and parent-child interaction (relationship)

Trauma Focused Parent Coaching Adaptation of Parenting Through Change – SAMHSA National Registry Evidence Base Practice and Programs (Patterson & Forgatch) Adaptation of Parenting Through Change – SAMHSA National Registry Evidence Base Practice and Programs (Patterson & Forgatch) Adaptation adds content specific for trauma – emotional regulation and self-care Adaptation adds content specific for trauma – emotional regulation and self-care Skill focused (more acceptable for Somali culture), not “therapy” focused Skill focused (more acceptable for Somali culture), not “therapy” focused Assessing need for further adaptations for cultural “fit” with Somali population Assessing need for further adaptations for cultural “fit” with Somali population

Trauma Focused Parent Coaching Advantages Advantages Not diagnosis driven for parent Not diagnosis driven for parent Use group format (better cultural fit) Use group format (better cultural fit) Skill focused Skill focused Active learning – role plays, mid-week check in calls, home work Active learning – role plays, mid-week check in calls, home work Challenges Challenges Intensive training for staff (9 full days; 1 ½ hr coaching weekly) Intensive training for staff (9 full days; 1 ½ hr coaching weekly) Child care, incentives, food, logistics, etc. Child care, incentives, food, logistics, etc. Making sure it works for our cultural populations Making sure it works for our cultural populations

Lessons Learned: To be effective we need to Work with children in the context of the family and larger community Work with children in the context of the family and larger community Provide community resources for children and families Provide community resources for children and families Focus on practical solutions; De-emphasize traditional mental health jargon Focus on practical solutions; De-emphasize traditional mental health jargon Listen, explore new ways of looking at things, and adapt our model as needed Listen, explore new ways of looking at things, and adapt our model as needed Collaborate with parents, community leaders, and religious leaders Collaborate with parents, community leaders, and religious leaders

Bienestar: Trauma Services for Immigrant Students A Project of the Robert Wood Johnson Foundation’s Caring Across Communities program Joshua Kaufman, L.C.S.W. LAUSD/RAND/UCLA Trauma Services Adaptation Center for Schools and Communities School Mental Health Services Los Angeles Unified School District

Welcome to LAUSD Current student population total: Current student population total: 877, ,010 Includes k-12 enrollment, community adult schools, and early education centers Includes k-12 enrollment, community adult schools, and early education centers The total area of LAUSD is 710 square miles. The district serves many cities and several unincorporated areas of LA County. The total area of LAUSD is 710 square miles. The district serves many cities and several unincorporated areas of LA County. 45% ELLs 45% ELLs 78% Title 1 eligible 78% Title 1 eligible 90% of students in Downtown schools are from Mexico and Central America 90% of students in Downtown schools are from Mexico and Central America

CBITS as Recommended Practice U.S. Department of Education: CBITS meets standards of the No Child Left Behind policy U.S. Department of Education: CBITS meets standards of the No Child Left Behind policy Recognized as evidence-based program by: Recognized as evidence-based program by: National Child Traumatic Stress Network National Child Traumatic Stress Network National Registry of Evidence-based Programs and Practices (NREPP) National Registry of Evidence-based Programs and Practices (NREPP) Promising Practices Network Promising Practices Network Office of Juvenile Justice and Delinquency Prevention (OJJDP) Office of Juvenile Justice and Delinquency Prevention (OJJDP)

Bienestar Program All services provided in Spanish by bilingual/bicultural clinicians. All services provided in Spanish by bilingual/bicultural clinicians. All treatment documents translated into Spanish All treatment documents translated into Spanish Addressing traumatic immigration experience, additional attachment issues of separation and reunion, and adjustment to “new life” Addressing traumatic immigration experience, additional attachment issues of separation and reunion, and adjustment to “new life” Tailoring intervention to older students Tailoring intervention to older students Weekly reflective supervision to provide support and monitor fidelity Weekly reflective supervision to provide support and monitor fidelity Adapting Evidence-Based services to meet the unmet needs of newly arrived immigrant students:

LAUSD Immigrant Center: Key Language Groups

Belmont High School’s Newcomer Center

Belmont Newcomer HS Teachers 2007 (N=13) Not relevant (15%) Very relevant (85%) Is trauma a relevant issue for students in Your classroom? Do teachers feel they need more training about trauma and students?

Violence Exposure & Symptomatology Belmont Newcomer Students (n=90) September 2007 Experienced multiple traumatic events Gun or knife violence Trauma symptoms in clinical range

Services - Year 1 Rec’d Bienestar CBITS: 9 Rec’d Bienestar CBITS: 9 Rec’d other adjustment groups: 13 Rec’d other adjustment groups: 13 Rec’d indiv/family support: 38 Rec’d indiv/family support: 38 Teacher trainings: Teacher trainings: Trauma Awareness Trauma Awareness Psychological First Aid Psychological First Aid

Opportunities Provide leadership in developing a coordinated system of care with schools as a cornerstone Provide leadership in developing a coordinated system of care with schools as a cornerstone Collaboratively develop culturally specific interventions that are effective by meaningfully involving the community Collaboratively develop culturally specific interventions that are effective by meaningfully involving the community Promote cross-cultural awareness/understanding and be willing to share power Promote cross-cultural awareness/understanding and be willing to share power Improve community health within immigrant communities and in the larger community Improve community health within immigrant communities and in the larger community Explore additional partnerships and opportunities for collaboration Explore additional partnerships and opportunities for collaboration

Contact Information Olga Acosta Price, PhD Olga Acosta Price, PhD Co-Director, Center for Health and Health Care in Schools Associate Research Professor, GWU Phone: Joshua Kaufman, LCSW Joshua Kaufman, LCSW LAUSD/RAND/UCLA Trauma Services Adaptation Center for Schools and Communities School Mental Health Services Los Angeles Unified School District Phone: Mark Sander, PsyD, LP Minneapolis Public Schools/Hennepin County Project Director, RWJF Initiative Coordinator, Expanded School Mental Health Program or Phone: