Assessing Asian children and adolescents (includes CALD Assessment Tool for Children)

In traditional Asian families children are highly valued and protected. They are taught to be quiet, humble, shy, polite and deferential. Emotional outburst are discouraged and conformity to expectations is emphasized. Failure to meet expectations brings shame and loss of face to the child and the family, so parents are often reluctant to accept that there is a mental health problem. Generally parents do not express affection or praise for fear of encouraging laziness.

Adolescence has little meaning in most Asian cultures as individuation has no value and seeking an identity outside the family is discouraged. However, after migration the adolescent faces the significant challenge of bridging opposing expectations in a new culture, and this often becomes a cause of intergenerational conflict. Ehthnolt & Yule (2006) note that whilst individualism is attainable for migrant Asian adolescents, individuation is not a likely option.

Assessing children and adolescents is best done in a semi-structured way in order to establish rapport, engage the child and collect information. It is especially important at the first interview when parents are usually included. Further interviews may need to be more structured, especially when assessing for diagnostic criteria, medico-legal reports etc.

Rho and Rho (2009) suggest that: 

• Having a parent or caregiver present may be useful in the initial interview.
• A qualified interpreter is important, the child should not be expected to act as interpreter.
• A holistic approach is mandatory when working with children.]
• Time should be taken to explain what a mental health worker is and what services are available.
• The use of questionnaires has been found useful, but care needs to be taken when analysing results as many scores are based on white British and American children. Allowances must be made for language and cultural differences.

Rho & Rho (2009) remind us that children either internalise (manifesting as depression or anxiety) or externalise (manifesting as disruptive behaviour) their emotions. Aggression and disruptive behaviour are more common in boys, whilst anxiety and adjustment issues tend to be more prevalent in girls. Depression, anxiety and sleep disturbances are common complaints in children, and depression and anxiety in Asian adolescents.

In New Zealand, schools tend to make the most referrals to mental health services, where social, interpersonal and family problems are of concern. Referrals made by caregivers are often influenced by culture and the caregiver's perceptions of emotional and behavioural problems.

The CALD Assessment Tool for Children has been adapted for use with children and adolescents. The information below is for use with the tool.

A. Cultural and ethnic identity

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 and 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 pluralistic culture they come from, this may not be acceptable.

According to Rho and Rho (2009) corporal punishment is commonly used in Asian countries, especially Korea. 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 like time-out, is very useful to parents. Educating the referring agencies about the need for cultural sensitivity is essential, as well as correcting misattributions like bruising that is caused by cupping and coining, and not by physical violence.

Engaging the family

Many Asian 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. Our individually oriented care is often not appropriate for clients where families make decisions, and independence and empowerment are not valued in the same way, or are at odds with families' wishes.

Problems arise in our approaches because:

• 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 others it may be due to confusion around multiple services and clinicians.
• The key caregiver in the family is not included 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 procedures or care plans.

Implications for practice

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

B. Explanatory models of illness

Children also have their own explanations for illness, so it is important to explore the child (as well as the family's) understanding of the problem, and their expectations and beliefs about outcome. Use questions from the CALD Assessment Tool for Children to explore this.