The purpose of this article is to discuss the complexities of working with anxious children and adolescents of diverse cultures within the context of cognitive-behavioral treatment. Our discussion will examine how culture, gender, and minority status affect anxious symptomatology in children and adolescents and how this may be addressed in treatment. The authors discuss the importance of considering the cultural variations in symptom expression, cultural norms and issues of acculturation, effects of discrimination, and finally the ways that gender can moderate symptom expression. Case examples are incorporated into each section. Recommendations include an emphasis on research on working with children of diverse cultures and the need for ongoing training that helps therapists to examine the impact of their own cultural beliefs on clinical care.
Keywords: anxiety; gender; culture; youth; children
Although research has demonstrated many similarities in the expression of anxiety among children, many differences also exist particularly with respect to how children of varying cultures report symptoms, respond to treatment and even respond to the therapist (Alfons, Achenbach, & Verhulst, 1997; Canino, 2004; Ginsburg & Silverman, 1996; Pina, Silverman, Fuentes, Kurtines, & Weems, 2003; Stewart et al., 2004; Yeh, Hough, McCabe, Lau, & Garland, 2004; Zane, Sue, Hu, & Kwon, 1991). Demonstrating sensitivity to observing these differences is critical for guiding our assessment and treatment strategies in order to optimize our work with children and families from diverse backgrounds. A concrete definition of culture is elusive. Culture can be loosely defined as a system of shared meanings, or more specifically "a common heritage or set of beliefs, norms and values" (U.S. Department of Health and Human Services, 1999). The emerging field of cultural competence speaks to the idea that these differences in beliefs and shared norms must be recognized and one must put forth effort to learn ways to not only "help" other cultures, but also seek to understand them (Stuart, 2004; Sue, 1998). There can be no blanket approach to working with individuals of diverse cultures, but instead a basic skill for a culturally competent therapist is to know "when to generalize and be inclusive and when to individualize and be exclusive" (Sue, 1998). This is not an innate skill, and requires an ability to be aware of and examine one's own assumptions and learn to apply this knowledge to treatment. It is a challenge to work with anxious children, and an additional challenge to work with anxious children of diverse cultures.
The 2001 supplement to the Surgeon General's Report on Mental Health found that "racial and ethnic minorities bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity" (U.S. Department of Health and Human Services, 2001). While the report touches only generally on the issues of culture and the mental health of minority children it is reasonable to conclude that the issues that affect adults likely impact their children as well. This article examines more closely the role of culture with respect to anxiety disorders in youth and provides suggestions for practitioners engaged in treating patients from many different cultures. We will discuss the ramifications of how various cultures define and express anxiety, how to engage families of anxious children in treatment, the effect of gender on symptom expression, assessing levels of acculturation and assimilation, and ideas for future research.
CULTURAL DIFFERENCES IN SYMPTOM EXPRESSION
Cultural influences in treatment begin with the first point of contact. Culture may impact why and when a family seeks treatment for their child, and whom they trust to approach for treatment. Approaching the initial assessment with these factors in mind can lead to a stronger understanding of cultural issues and a stronger alliance between the family and therapist. …