CALD assessment tool (2)

Conducting culturally sensitive interviews with a young child can be challenging, particularly if the parents do not understand why they have been referred. They may be hesitant to disclose details about the child's behaviour at home if they do not know why they are being asked for the information (Rho & Rho, 2009). It is important to understand the parent's expectation of the child's development and behaviour, and whether they see the issue as problematic in their own culture.

Using culturally sensitive assessment toys and gaining insight into what behaviour is regarded as acceptable at home, can help the clinician to understand the reason for referral. Children may be encouraged to be assertive and outspoken at school, but in the collectivist culture they come from, this may not be acceptable.

Corporal punishment is commonly used in traditional societies (Rho & Rho, 2009). When children get referred to clinicians by child protection services, it is important to treat the parents in a culturally sensitive, non-shaming way and to explain that in New Zealand alternative forms of punishment are preferred and that corporal punishment is illegal. Normalising the behaviour in an understanding way and providing guidance on alternative forms of punishment such as time-out, is very useful to parents. Educating parents through language appropriate parenting programmes such as the Incredible Years Programme (IYP) will assist with developing parenting skills in the New Zealand context.

Assessing migrant Asian/MEA children who are in the process of acculturating can be challenging. These children are navigating their way through developmental milestones in a new culture, language and society. Because developmental processes can be disrupted during migration due to acculturation (as well as pre-migration experiences for children from refugee backgrounds), it can be difficult to assess developmental stages in the context of cultural norms.

Age at the time of migration is an important factor when assessing cultural differences in expression of psychological symptoms (including somatisation). The influence of acculturation is more obvious in those adolescents who migrated at a young age (Chan & Parker, 2004).

Rho and Rho (2009) suggest taking the following cultural factors into account when conducting assessments

Children:

• When assessing children's development, it is important to bear in mind that childhood milestones can be culturally based (eg expectations for toileting skills can vary from 4 months to 4 years, ages at which children walk or talk can depend on child-rearing practices, etc.).
• In many cultures, children are expected to be 'seen and not heard' and may not communicate assertively with adults, whilst in other cultures children are the centre of attention and are accorded many privileges until a certain age. Expressiveness, both vocal and physical may differ significantly across cultures.

Adolescents

• It is important to assess whether identity has been established. Emerging independence in adolescence, recognised in Western cultures, may not be relevant to other cultures. In collectivist cultures where modesty, respect, courtesy and loyalty are valued, independence is usually not valued. Conflict may occur within families, but also within the adolescent who is caught between two cultures and is trying to define themselves, their values and their beliefs.
• Sexuality issues, interethnic relationships and taboo subjects like homosexuality will need to be explored in a very sensitive way.
• If delinquency issues are involved, referral to school liaison teams may be needed. However, parents may need to be educated about the process and this will require careful cultural consideration.
• Due to peer pressure to join a new culture, and adjustment difficulties, drug and alcohol abuse may be a problem. Psychoeducation on addiction issues may not be accessible to parents due to language barriers.

Engaging with family

Many CALD children are likely to come from families that are family-centered, with extended members, rather than from nuclear families. It is important to ask who the main caregiver and /or decision maker is and to involve them in the process of assessment, intervention and treatment. Individually oriented care is often not appropriate for clients where families make decisions about treatment and care. In collectivist cultures, children and young people’s independence and empowerment are not valued in the same way, or may be at odds with families' wishes. Explore the role of religion and the church/ mosque/ temple for the family.

Potential problems may arise if:

• Individuals and not families are consulted.
• There is insufficient understanding about how family structures differ across cultures, and who is included in family boundaries.
• Key family members are not included in consultations and treatment plans and so do not support, or may even prohibit proposed interventions.
• Family members attending the consultations may not fully understand the plans or reasons for them and are unable to convey these to the head of the family. Sometimes the misunderstanding is because of language or lack of familiarity with the medical terminology, at other times it may be due to confusion around multiple services and clinicians. Identify the key caregiver in the family and include them in the consultations. This person is not always a parent, and may also not be the key decision maker. If they are not involved they may not understand or be invested in intervention and treatment plans.

Implications for practice

• Involving parents or family in the assessment of a CALD child is helpful in establishing acculturation rates for the child and parents. Acculturation, and differences in levels between parent and child, may be at the root of a problem, but may not be obvious in the presenting issue.