According to a recent report of the Surgeon General (U.S. Department of Health and Human Services 1999), a range of treatments exist for most mental disorders, and the efficacy of those treatments is well documented. However, a supplement to that report (U.S. Department of Health and Human Services 2001) notes that minorities are largely missing from the efficacy studies that make up the evidence base for treatments. Because of this omission, questions arise as to whether it is appropriate to advocate for providing evidence-based care for minority populations. Do efficacious treatments generalize to minority populations? Should we adapt care for each cultural group? Does poverty affect outcomes of care? If we were better able to encourage ethnic minorities to enter care, would outcomes be similar to those found for majority patients? New data have become available regarding the impact of mental health interventions on ethnic minorities. Although data are not available to answer each question posed above, we examine what is known about outcomes of mental health treatments for ethnic minorities and begin to answer these important questions about providing care to our growing and diverse ethnic minority populations.

Outcomes of mental health care are obtained through two types of research, efficacy and effectiveness studies. Efficacy studies, or randomized, controlled trials, are useful in identifying the outcomes that are likely to be associated with precisely defined care provided by experts. These studies identify the impact of interventions on outcomes, such as decreases in psychiatric symptoms and remission of syndromes. The goal of efficacy studies is to determine whether or not an intervention works for a specific syndrome. Thus, the populations studied need to meet criteria for that syndrome and be relatively free of comorbid disorders. Furthermore, highly trained, specialized clinicians provide the care under carefully specified conditions. To date, these studies have predominantly been conducted in nonminority populations; well-controlled efficacy studies examining outcomes of mental health care for minorities are rarely available. In fact, in an analysis conducted for the report of the Surgeon General entitled “Mental Health: Culture, Race and Ethnicity” (U.S. Department of Health and Human Services 2001), it was found that of 9266 participants involved in the efficacy studies forming the major treatment guidelines for bipolar disorder, schizophrenia, depression, and attention deficit/hyperactivity disorder (ADHD), only 561 Black, 99 Latino, 11 Asian American/Pacific Islanders, and zero American Indians/Alaskan Natives were included. Few of these studies had the power necessary to examine the impact of care on specific minorities. In this chapter, we examine available data from treatment outcome studies with minorities.

Effectiveness studies are also important when thinking about outcomes of psychosocial interventions because these studies help evaluate outcomes of care given in real-world settings. Once an intervention is found to be efficacious, effectiveness studies then determine how they work within more diverse (both in terms of diagnosis and comorbidities) populations and when given by less-specialized clinicians. Clinicians in effectiveness studies are more likely to be generalists working in clinical settings. Outcomes often include factors such as whether or not care is sought, length of care, and adequacy of interventions. In addition, because of generally larger sample sizes, some of these trials are able to examine outcomes associated with not only symptom reduction, but also with functioning, quality of life, and cost effectiveness of care. Newer studies tend to include more diverse samples and a few have specifically included a minority sample. Again, we examine data available for minorities and compare outcomes with nonminority samples.

State of the science on psychosocial interventions for ethnic minorities.

Carstensen's selectivity theory, which explains age-related change in social behavior in terms of emotion conservation and increasing discrimination among social partners, was investigated in 2 studies. In Study 1, 80 people aged 14 to 95 classified descriptions of people according to their similarities as social partners in terms of affect anticipated in the interaction and that this dimension was most important to older people. Study 2 showed how anticipated social endings influence partner selection: 380 people aged 11 to 92 chose familiar or novel partners under unspecified and ending conditions. Overall, older people chose familiar partners most frequently; yet when social endings were salient, younger people patterned the preferences of the elderly. These results suggest that social partner selectivity functions to conserve emotion resources in the face of limited future opportunities.

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Choosing social partners: how old age and anticipated endings make people more selective.

The present study reports the results of a prospective, 8-year follow-up study of 100 hyperactive and 60 normal children followed from childhood into adolescence. Ratings of child behavior problems and family conflicts as well as direct observations of mother-child interactions were taken in childhood and again at adolescent follow-up. At outcome, hyperactives continued to have more conduct and learning problems and to be more hyperactive, inattentive, and impulsive than controls. Hyperactives were also rated by their mothers as having more numerous and intense family conflicts than the normal controls, although the adolescents in both groups did not differ in their own ratings of these conflicts. Observations of mother-adolescent interactions at outcome found the hyperactive dyads displaying more negative and controlling behaviors and less positive and facilitating behaviors towards each other than in the normal dyads. These interaction patterns were significantly related to similar patterns in mother-child interactions observed 8 years earlier. Mothers of hyperactives also reported more personal psychological distress than normal mothers at outcome. Further analyses of subgroups of hyperactives at outcome, formed on the presence or absence of ADHD and oppositional defiant disorder (ODD), indicated that the presence of ODD accounted for most of the differences between hyperactives and normals on the interaction measures, ratings of home conflicts, and ratings of maternal psychological distress. Results suggest that the development and maintenance of ODD into adolescence in hyperactive children is strongly associated with aggression and negative parent-child interactions in childhood.

The adolescent outcome of hyperactive children diagnosed by research criteria--III. Mother-child interactions, family conflicts and maternal psychopathology.

Twenty-eight factor- and cluster-analytic studies of child psychopathology were examined for patterns in antisocial behavior. A multidimensional scaling analysis yielded one dimension that was labeled overt-covert antisocial behavior. One end of this dimension consisted of overt or confrontive antisocial behaviors such as arguing, temper tantrums, and fighting. The other end consisted of covert or concealed antisocial behaviors such as stealing, truancy, and fire setting. Implications derived from the present findings are discussed as they apply to the diagnosis, prevention, and treatment of antisocial behaviors in children.

Empirical evidence for overt and covert patterns of antisocial conduct problems: a metaanalysis.

We conducted a meta-analysis of 99 studies that used interventions to decrease disruptive classroom behavior in public education settings. Due to the predominance of single-subject studies, we used...

A Meta-Analysis of Interventions To Decrease Disruptive Classroom Behavior in Public Education Settings.

The purpose of this study was to develop a self-instructional package that would aid highly distractible children in increasing their attending behavior in a training and two generalization (a one-to-one and a classroom) situations. Three untrained subjects were monitored for general comparison and social validation purposes. One of these control subjects was distractible and the other two (criterion comparison) were evaluated as not having attentional problems. A multiple baseline design was employed in which training was sequentially introduced across subjects. During training, the experimental subjects were taught through self-instruction to focus their attention and to cope with two tasks, math and printing. After learning the self-instructions the subjects were systematically and sequentially exposed to photo-slides of distracting situations, to audio-distractors composed of noisy lunchroom verbal peer interactions, and to in vivo distractors provided by kindergarten children playing with wooden blocks in the training setting. The entire training procedure was handled in a game-like context to maintain subject interest and to facilitate generalization. The results suggested that the training package produced direct and generalized changes in self-instructional behavior. In addition, a decreae in off-task behavior occurred during math, printing, and also during a phonics program in the one-to-one and classroom situations. However, reliable changes in academic task performance were not observed. Finally, no systematic changes on any of the dependent measures occurred for the three untrained subjects.

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A self-instructional package for increasing attending behavior in educable mentally retarded children.

Except for a few studies, most research investigating correspondence training procedures has been more analogue in nature. The purpose of the present set of studies was to examine whether a "say-do" correspondence training technique could be used with children in special education classes to improve classroom behavior. The specific behaviors targeted for change included: out-of-seat behavior (Experiment 1), sitting posture (Experiment 2), and on-task behavior (Experiment 3). The say-do procedure used in Experiment 1 resembled that of previous studies, whereas that in Experiment 2 was more elaborate in the specificity of verbal statements required from the children and the feedback given them. The training procedure in Experiment 3 used a format similar to the say-do approach, but stressed visual rather than verbal cuing because it was used with nonverbal children. All three studies used single-subject designs and examined maintenance and/or generalization questions. Experiments 2 and 3 also evaluated whether concomitant changes in performance on academic tasks occurred. The results of the three studies provide strong evidence that correspondence training can be effectively used with educationally handicapped children. Moreover, the successful modification of the "say-do" to a "show-do" procedure in Experiment 3 points out the flexibility of the correspondence training approach.

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Improving classroom behavior in mentally retarded children through correspondence training.

Teaching addition and subtraction to mentally retarded children: a self-instruction program.

A systematic replication of the "good behavior game" and manipulation of teacher attention for reducing disruptive behavior in two classrooms were studied. The game plus teacher attention proved effective for reducing a variety of disruptive behaviors (e.g., talking out, out-of-seat, cursing, etc.), as well as decreasing teacher attention to these behaviors. Although disruptive behavior and teacher attention to it were successfully treated with the procedures, both student and teacher behavior showed marked increases across postcheck sessions after treatment was no longer monitored by the experimenter. Language: en

The "good behavior game": a systematic replication in two unruly transitional classrooms

First-grade children engaged in seatwork behaviors under reinforcement schedules established according to the Premack Principle and the Response Deprivation Hypothesis. Across two experiments, schedules were presented to the children in a counter-balanced fashion which fulfilled the conditions of one, both, or neither of the hypotheses. Duration of on-task math and coloring in Experiment 1 and on-task math and reading in Experiment 2 were the dependent variables. A modified ABA-type withdrawal design, including a condition to control for the noncontingent effects of a schedule, indicated an increase of on-task instrumental responding only in those schedules where the condition of response deprivation was present but not where it was absent, regardless of the probability differential between the instrumental and contingent responses. These results were consistent with laboratory findings supporting the necessity of response deprivation for producing the reinforcement effect in single response, instrumental schedules. However, the results of the control procedure were equivocal so the contribution of the contingent relationship between the responses to the increases in instrumental behavior could not be determined. Nevertheless, these results provided tentative support for the Response Deprivation Hypothesis as a new approach to establishing reinforcement schedules while indicating the need for further research in this area. The possible advantages of this technique for applied use were identified and discussed.

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Moses R. Johnson

Papers

A self-instructional package for increasing attending behavior in educable mentally retarded children.

Improving classroom behavior in mentally retarded children through correspondence training.

Teaching addition and subtraction to mentally retarded children: a self-instruction program.

The "good behavior game": a systematic replication in two unruly transitional classrooms

Response deprivation and reinforcement in applied settings: A preliminary analysis