The Role of Theory and Culture in Child and Adolescent Prevention Science: Introduction to the Special Section

The 2009 Institute of Medicine's report on Preventing Mental, Emotional, and Behavioral Disorders among Young People concluded that there is strong and consistent evidence supporting the promise and potential benefits of preventing mental, emotional, and behavioral disorders in children and adolescents. The report also highlighted that a number of preventive interventions are available for large-scale implementation with the caveat that there is a scarcity of research demonstrating that evidence-based interventions are transportable to a range of ethnic and cultural groups (IOM, 2009, p. 336). As such, ensuring that individuals at risk receive the best available evidence-based interventions prior to the onset of a disorder is limited because a significant and growing segment of the population (i.e., children and families of color) remains underrepresented in prevention science research. Toward the aim of advancing greater inclusion of diverse populations in the next generation of prevention research, this special section reports on four exemplary research programs that each have taken a different approach to enhance or test the cultural robustness of an intervention for use with distinct ethnic and cultural groups. This topic is timely for the Journal of Clinical Child and Adolescent Psychology because it addresses shortcomings in meeting the needs of children and families that are also relevant to empirically supported treatments (see 2008 Special Section published in this Journal), and because the field of prevention science has now produced an impressive body of evidence to support its inclusion in a comprehensive, integrated agenda to improve children's mental health at the population level (Weisz, Sandler, Durlak, & Anton, 2005). Accumulated findings now indicate that prevention science offers an avenue for reducing the incidence of child psychiatric disorders as promising as psychological treatment science (see IOM, 2009).

The papers selected for this special section draw on the growing body of research on cultural adaptation that has identified challenges and systematic strategies for adapting or modifying evidence-based interventions (treatment and prevention) to consider language, culture, and context in such a way that it is compatible with the client's cultural patterns, meanings, and values (Bernal & Domenech-Rodríguez, 2012; Barrera et al., 2013; Holly, Chiapa, & Pina, in press). However, in contrast to many cultural adaptations of interventions previously published, these papers articulate the theoretical framework guiding the intervention and the way in which cultural dimensions were considered and strategically integrated within this framework to address their targeted outcomes and unique populations. As a group, these papers also address a central theme of “culturally robust adaptation” which is defined here as cultural adaptations that are broadly applicable or responsive (vs. narrow) with respect to diversity that exists within or between cultural groups and contexts.

Cultural adaptation takes the position that, to be effective, interventions must be responsive to the cultural practices and worldviews of the subcultural groups for whom these interventions are intended (Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000). Clearly, this view has gained significant traction over the years as the diversity of the U.S. population has expanded exponentially; however, the issue of culture continues to be a matter of significant debate with strong arguments still voiced about the wisdom, necessity, and feasibility of this position (Elliot & Mihalic, 2004; Ortiz & Del Vecchio, 2013). Opposing arguments counter that the adaptation of interventions for increasingly smaller segments of the population is not feasible given the number of treatments, disorders, developmental stages, and a host of other factors that would generate a matrix impossible to manage (Kazdin, 2008). Moreover, many interventions will ultimately be delivered in multicultural settings, across diverse contexts, or with populations that are changing on cultural dimensions. If the ultimate goal is to produce sustainable interventions for broad public health impact, it may be necessary to develop culturally robust adaptations that are more flexible or adaptive with respect to culture.

The special section opens with a cross-ethnic comparative study focusing on the prevention of disruptive behavior problems in children and adolescents that uses a well-established intervention, the Family Check-up (FCU) (Dishion & Stormshak, 2007). Guided by family theory, two critically important questions are asked by (Smith, Knoble, Zerr, Dishion, & Stormshak): (1) Do program effects vary as a function of ethnicity? (2) Do key assumptions about mechanisms of change inherent in the intervention account for the observed prevention effects across ethnic groups. In answering these two core questions, the authors present the cultural theory that has guided their intervention efforts for decades as well as its fit with the sociocultural contexts in which they conduct their work. The second article in the special section moves beyond evaluating the cultural robustness of a mainstream intervention and instead describes a culture specific protocol aimed at reducing the risk for externalizing and internalizing mental health problems while promoting academic engagement in a specific segment of the U.S. population (i.e., Mexican American adolescents attending schools in low-income communities). Bridges/Puentes (Gonzales, Dumka, Millsap, Gottschall, Mcclain, et al., 2012) is an exemplar of culturally grounded prevention, and in this special section Jensen, Wong, Gonzales, Millsap and Coxe present a test of a culturally informed putative mediator of program response while asking the question of whether hypothesized mechanisms of change operate similarly for families that vary in level of acculturation. Their analyses are unique in providing a test of cultural robustness with respect to diversity within a distinct ethnic group which is a critical question given the tremendous heterogeneity of Latinos in the U.S.

Turning to the second half of the special section, the subsequent two articles focus on models of cultural adaptation that extend beyond the traditional ways cultural tailoring has been pursued over the past decades (see Bernal, Bonilla, & Bellido, 1995; Bernal & Domenech Rodríguez, 2012; Castro et al., 2004; Falicov, 2009; Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000). In the third article, McKernay McKay, Alicea, Elwyn, McClain, Parker, Small, and Mellins describe the theoretical evolution of the CHAMP family program (McKay & Paikoff, 2007) as it positioned itself to become a global force requiring adaptations to new contexts. McKernay McKay and colleagues, articulate how conceptual frameworks based on adolescent development, ecological development perspective, Triadic Theory of Influence, and Social Action Theory were weaved to make CHAMP successful in the specific contexts of poverty-impacted communities worldwide. This third article serves as an exemplar of how theory and the role of culture can help inform HIV intervention efforts that address the needs of people within their unique community and cultural contexts. Finally, the fourth article offers a window into a possible future characterized by a generation of strategic and systematic cultural adaptation efforts for prevention science. Pina, Holly, Zerr, and Rivera describe an approach to ideographically apply cultural considerations to prevention interventions using a quantitative assessment and feedback method, based on control systems engineering (Rivera, Pew, & Collins, 2007; Navarro-Barrientos, Rivera, & Collins, 2010). In particular, focusing on child anxiety prevention efforts, the fourth article illustrates an innovative approach to designing, testing, and delivering culturally responsive evidence-based care in a way that considers within-group (and within-family) variability. Pina et al. offer a vision that is both timely and important given recent interest in adaptive intervention designs (Collins, Murphy, & Bierman, 2004).

Collectively, the special section offers a selection of articles that articulate the conceptual underpinnings guiding unique intervention efforts and describe how culture was (and could be) integrated in the underlying models, design, or delivery of intervention(s) focused on ameliorating major child mental, emotional, and behavioral problems. Tests of cultural robustness were provided in the first two articles using existing data (longitudinal, cross-sectional, and experimental) whereas rich illustrations of ongoing and future plans to advance evidence-based, culturally robust preventive intervention toward successful dissemination were offered in the last two articles. In closing, we hope this special section facilitates new and innovative intervention efforts with true potential for meeting the needs of children and families of color in the United States and worldwide.