Cultural and linguistic considerations in psychodiagnosis with Hispanics: the need for an empirically informed process model.

It is estimated that in the next century nearly half of the clientele seeking mental health services will be members of ethnic minority groups. Hispanics are the most rapidly growing population in the United States, and epidemiological evidence suggests that they present higher levels of psychiatric symptomatology and prevalence rates of disorder compared with other ethnic groups. Despite the unprecedented recognition of cultural considerations found in DSM-IV for rendering a psychiatric diagnosis, there is still surprisingly little empirical research examining cultural and linguistic factors influencing the diagnostic process. This article critically reviews this research and considers process variables that can inform social workers' culturally sensitive diagnosis of Hispanics.

Thematic instrument for measuring death anxiety in children (TIMDAC).

Few instruments measure death anxiety in children, especially, children of color. This article describes the development and psychometric properties of the projective instrument, the Thematic Instrument for Measuring Death Anxiety in Children (TIMDAC), a culturally sensitive tool that was developed to compare levels of death anxiety in children diagnosed with acquired immune deficiency syndrome (AIDS) and health peers. Many of the children with AIDS are African Americans and Latinos.

Alcohol and drug use, and depression among Hispanic men in early adulthood.

Community research and clinical practice have shown that alcohol and drug use and depression are interrelated. Among Hispanics, acculturation may play a role in these relationships. To investigate these relationships as well as alcohol-related problems, we interviewed 288 Puerto Rican, Dominican, and Colombian men in early adulthood. No significant differences emerged in the proportions of abstainers across the three groups. Colombians drank significantly more frequently and had more alcohol-related problems than Dominicans. Dominicans were at least risk for and least likely to have alcohol-related problems. Puerto Ricans were much more likely to use drugs than the other Hispanic men. Drug use was associated with an increased likelihood of heavy drinking which, in turn, increased the risk of drug use and depression. Acculturation decreased the risk of drug use. Results are discussed in terms of implications for community psychology research and interventions.

Alcohol and marijuana use among rural youth: interaction of social and intrapersonal influences.

Epidemiological research indicates that the prevalence rate of drug use among adolescents has risen steadily during this decade, and although alcohol use has stabilized it is still highly prevalent. Psychosocial etiological models have typically examined main effects of risk and protective factors. This study examined moderating effects of intrapersonal skills on social (peer and parental) risks associated with alcohol and marijuana use among eighth-grade rural adolescents, an understudied population. Results indicated that the relationships of peer and parental attitudes, and peer usage to alcohol and marijuana use, are moderated by adolescents' decision-making and self-reinforcement skills. Social risk factors were strongly associated with increased alcohol and marijuana use among adolescents with poor intrapersonal skills. However, good decision-making and self-reinforcement skills diminished the influence of social risk factors on substance use. Results are discussed in terms of implications for psychosocial models of alcohol and drug use, and for designing effective school-based universal prevention interventions.

Biculturality among Puerto Rican adults in the United States.

Identified the concept of acculturation as a cornerstone of immigration research, while questioning assumptions about zero-sum cultural change in acculturation scales and in procedures assessing biculturality. Involvements in the host society culture and the culture of origin should be assessed separately in order to reflect the complexities of the cultural interactions immigrants and their offspring experience. To evaluate this prescription, we convened focus groups of Puerto Rican adults to discuss their cultural experiences in Puerto Rico and in the United States. Discussions were content analyzed to develop acculturation items. Factor analysis of the responses of 403 first- and second-generation adults yielded two general factors, involvement in American culture and involvement in Puerto Rican culture, which demonstrated modest reliability, relative independence, and moderate correlations with traditional acculturation scale validators. Results of the study challenge the assumption of mutual cultural exclusivity in acculturative change; enable the measurement of degree of biculturality; and provide future directions for the assessment of acculturation in domains other than language usage. The concept of acculturation is integrated with recent formulations in community psychology which advocate a deeper and more extensive commitment to studying the implications of cultural phenomena and greater focus on the growing cultural diversity in the United States.

The mental health relevance of idioms of distress. Anger and perceptions of injustice among New York Puerto Ricans.

Cultural sensitivity in mental health research is enhanced by examining the collective perceptions of members of ethnic groups about their own idiomatic expressions of distress. Such an examination was conducted with Puerto Ricans living in New York City, beginning with focus group discussions. Their prevailing idioms of distress, based upon themes of anger and injustice, were correlated widely with professionally developed measures of anxiety, depression, and somatization and with utilization of professional mental health care. By examining the relationship between idioms of distress, saliently volunteered by members of the ethnic ingroup, on the one hand, and professional care and assessments of mental health, on the other, we increase our culturally based understanding of mental health in the community.

Mental health status among Puerto Ricans, Mexican Americans, and non-Hispanic whites: the case of the misbegotten hypothesis.

Challenged Shrout et al.'s (1992) comparisons of mental health characteristics of island Puerto Ricans to Mexican Americans and non-Hispanic whites from the Los Angeles Epidemiological Catchment Area Study. The hypothesis tested by Shrout et al.--higher symptom counts but lower DSM-III prevalence rates among Puerto Ricans--was misattributed to Rogler (1989). We also question the validity of assessing lifetime prevalence and reaffirm the need for psychiatric epidemiological research to consider the role of culture in diagnostic criteria.

Clinical utility of the TEMAS with nonminority children.

The Tell Me a Story (TEMAS) Test is a thematic apperception technique composed of 23 chromatic pictures, depicting either minority or nonminority characters interacting in primarily urban and familial settings, and is scored for perceptual and cognitive style, affective state, and personality functioning. Previous research has supported the reliability and validity of the ethnic minority version of the TEMAS test for Hispanic and Black children and adolescents. In this study, we investigated the validity of the nonminority version by discriminating public school (n = 49) and outpatient (n = 36) samples of White examinees from inner city, low to lower middle socioeconomic status, largely female-headed households. Results indicate that TEMAS profiles significantly discriminated between the normal functioning and clinical groups (p < .001), with 86% classification accuracy. The results, which provide some support for the general clinical utility of the TEMAS technique, are discussed in terms of the need to develop and validate unbiased projective techniques for both ethnic minority and nonminority children.

Evaluation of mental health. Issues of memory in the Diagnostic Interview Schedule.

Research on the Diagnostic Interview Schedule, the chief instrument in contemporary studies in psychiatric epidemiology, has supported its utility in enabling lay interviewers to reproduce psychiatric interviews within an acceptable margin of error. Nonetheless, we propose that the Diagnostic Interview Schedule commits itself to dubious assumptions regarding the accuracy of human memory, shared by other history-taking efforts, by relying on retrospective reports of lifetime DSM-III symptoms and episodic dating of symptom spells. For more than a century, the fallibility of human memory has been the topic of intensive experimental and naturalistic study, a history which is relevant to the construction of instruments like the Diagnostic Interview Schedule. The continuing use of retrospective lifetime symptom reports suggests that this literature has been largely ignored in the development and administration of the Diagnostic Interview Schedule. Prospectively organized research is needed to disclose the limits of human memory for recent psychiatric events and the mediating conditions under which memory for such events can be accurately retrieved and improved.

Issues of validity in the Diagnostic Interview Schedule.

The Diagnostic Interview Schedule, the chief instrument in contemporary studies in psychiatric epidemiology, enhances the reliability of psychiatric diagnosis and enables lay interviewers to closely reproduce psychiatric interviews. However, despite frequent references in the literature to the validity of the Diagnostic Interview Schedule, most studies fundamentally represent variations of reliability paradigms to the neglect of criterion-related validity. Mistaken assertions of validity persist in the psychometric language used to describe the Diagnostic Interview Schedule. This article examines the basis for claims and counterclaims of validity in accordance with standard psychometric definition, and identifies sources of erroneous reasoning in attempts to infer validity from reliability. The article presents a general framework organizing the process of diagnostic validation and discusses strategies for research seeking to validate psychiatric diagnoses achieved through the Diagnostic Interview Schedule.

Assessment of attention deficit disorder using a thematic apperception technique.

Attention deficit-hyperactivity disorder (AD-HD) is regarded as being relatively common among school-age children, but the literature reveals a number of confounding factors with standard assessment techniques of the disorder. Using a structured thematic apperception technique (the Tell-Me-A-Story [TEMAS] test) to measure attention to pictorial stimuli depicting characters, events, settings, and covert psychological conflicts, a study was conducted with 152 normal and 95 clinical Hispanic, Black, and White school-age children. Results reveal that the AD-HD children are significantly more likely than normal children to omit information in the stimuli about characters, events, settings, and psychological conflicts. Differences between the groups are large and persistent in the presence of structured inquiries by the test examiners. Results suggest the potential utility of structured thematic apperception techniques for the assessment of AD-HD, eventually to facilitate DSM-III-R (American Psychiatric Association, 1987) diagnosis, but also to invite closer scrutiny in carefully controlled validity studies.

Acculturation and mental health status among Hispanics. Convergence and new directions for research.

Acculturation, the process whereby immigrants change their behavior and attitudes toward those of the host society, is a fundamental part of migration-induced adaptations to new sociocultural environments. A rapidly expanding research literature on acculturation has accompanied the growth of international migrations. In response to the need to integrate the growing literature on acculturation and mental health status among Hispanics in the United States, and to identify points of convergence and new directions for research, 30 publications were examined. Points of convergence are identified, as are problems and limitations. The research needs new directions, proceeding from but not constricted by the assumptions and procedures in the work already done.

Culturally sensitive psychotherapy for Puerto Rican children and adolescents: a program of treatment outcome research.

Recognition of cultural distance between Hispanic clients and non-Hispanic therapists has prompted efforts to introduce culture into therapy, but there is little evidence that such efforts influence treatment outcomes. This article evaluates treatment outcomes from a program of research on modeling therapy with Puerto Ricans, targeting anxiety symptoms, acting-out behavior, and self-concept problems. Evaluation of outcomes confirmed the impact of culturally sensitive modeling therapy on anxiety symptoms and other selected target behaviors, but negative treatment effects also were evident. Results suggest that new approaches to psychotherapy for special populations, such as Hispanic children and adolescents, should be buttressed by programmatic research oriented toward the comparative evaluation of treatment outcomes and should be attuned to therapeutic processes mediating between culture and outcome.

Hero/heroine modeling for Puerto Rican adolescents: a preventive mental health intervention.

Culturally sensitive treatments of the special mental health needs of high-risk Puerto Rican adolescents are lacking. The hero/heroine intervention was based on adult Puerto Rican role models to foster ethnic identity, self-concept, and adaptive coping behavior. 90 nonclinical Puerto Rican 8th and 9th graders were screened for presenting behavior problems in school and randomly assigned to an intervention and a control group. After 19 sessions, the intervention significantly increased adolescents' ethnic identity and self-concept and reduced anxiety. Treatment outcomes varied as a function of grade level, sex, and household composition. Self-concept was negatively affected among girls from intact families. The study supports the effectiveness of the culturally sensitive modality as a preventive mental health intervention for high-risk Puerto Rican adolescents, especially from single-parent families.

Folk hero modeling therapy for Puerto Rican adolescents.

Puerto Ricans are concentrated in the Northeastern United States in predominantly low socioeconomic status, urban Hispanic communities. Due to a constellation of stressors associated with their minority status, bilingualism and bicultural conflicts, Puerto Rican adolescents are at high risk of mental disorder. Research has shown that factors such as migration experiences, low socioeconomic status, and Hispanic values conflicting with Anglo culture (e.g., familism, spiritualistic and folk beliefs, orientation to time) are associated with higher rates of psychiatric symptomatology in the Hispanic population. Community mental health resources are under utilized, and traditional therapy modalities have had limited success in remedying the emotional and behavioural problems of Hispanics. This paper reviews several approaches to the delivery of culturally sensitive mental health services to Hispanic populations and describes the development of a new modality for Puerto Rican adolescents. The modality presents Puerto Rican folk heroes and heroines in a modelling therapy targeted towards enhancing adolescents' pride in their ethnic heritage, self-esteem, and adaptive coping with stress. The therapy was implemented on a small-group basis with 21 Puerto Rican adolescents, some of whom participated with their mothers. A clinical evaluation of the therapy was conducted by summarizing therapists' progress reports on each participant and by interviewing the participants about their impressions of the therapy experience. Progress reports and participants' self-reports indicated that the adolescents increased in self-disclosure and self-confidence; they gained pride in being Puerto Rican; they learned adaptive mechanisms for coping with stress; and they enjoyed learning about famous Puerto Ricans and their culture.

Discriminant analysis of clinical outpatients and public school children by TEMAS: a thematic apperception test for Hispanics and blacks.

This study investigated the utility of the minority version of the Tell Me a Story (TEMAS) test, a thematic apperception technique for minorities and nonminorities, by discriminating public school and clinical Hispanic and Black children. The test is composed of 23 stimuli, depicting minority characters interacting in urban settings, and is scored for nine personality functions (e.g., aggression and anxiety). The subjects were 100 outpatients at psychiatric centers and 373 public school students, all from low socioeconomic (SES), inner city families. All subjects were tested individually by examiners of the same ethnicity. Results indicated that TEMAS profiles significantly, p less than .001, discriminated the two groups and explained 21% of the variance independent of ethnicity, age, and SES. Classification accuracy, based on the discriminant function, was 89%. The TEMAS profiles interacted with ethnicity; better discrimination was evident for Hispanics than Blacks. Results are discussed in terms of the need to develop and validate culturally sensitive personality tests for ethnic minorities.