Creating culturally responsive practice and services to support the mental health of children from culturally and linguistically diverse (CALD) backgrounds

Who is this resource for?

This resource is for managers, practitioners and support staff at services working to support the mental health and wellbeing of children and families (e.g. mental health services, community service organisations). This resource will be particularly useful for those working directly with CALD families, or who work in communities with significant cultural or linguistic diversity.

Definitions

Culturally and linguistically diverse (CALD): CALD communities are inconsistently defined in Australia (Pham et al., 2021). In this resource we draw on the Ethnic Communities Council of Victoria’s (2012) definition:

‘A broad term used to describe communities with diverse languages, ethnic backgrounds, nationalities, traditions, societal structures and religions’ (Ethnic Communities Council Victoria, 2012).

Although we use the term ‘CALD’ we recognise the diversity of populations this represents, including the various migration experiences and cultural, ethnic and religious backgrounds of families. Findings from research on CALD backgrounds or communities therefore cannot be generalised to individual experiences (Federation of Ethnic Communities’ Councils of Australia, 2020).

In this resource, CALD does not refer to Aboriginal and Torres Strait Islander populations.

Culturally responsive practice: There are multiple terms describing the adaptation of practices and services to make them more culturally responsive. These include ‘cultural competence’, ‘culturally informed’, ‘culturally responsive’, and ‘culturally-centred practice’. The term ‘cultural responsiveness’ is regarded as inclusive of ethnicity and other cultural identities (Victorian Transcultural Mental Health, 2022).

With Australia’s growing multicultural population (Australian Bureau of Statistics, 2022), mental health services must ensure they are inclusive for families and children from CALD backgrounds. Culture plays a significant role in how people experience and seek support for mental health issues (Victorian Transcultural Mental Health, 2020). Children and families from CALD backgrounds can face barriers in accessing mental health services or may not seek support for their needs.

Applying culturally responsive practice is one way to reduce barriers to help-seeking and create more relevant, inclusive and equitable services (Mental Health in Multicultural Australia [MHiMA], 2014). Culturally responsive practice goes beyond simply acknowledging and respecting different cultures and involves understanding the diversity of CALD communities and their specific issues and needs. It also requires partnering with CALD communities to adapt and deliver mental health services that respond to these identified community needs (MhiMA, 2014).

Some evidence suggests that child mental health difficulties in CALD populations can be harder to detect and/or that children may face barriers to accessing appropriate services (Nguyen et al., 2019).

Children from non-English-speaking immigrant families, or families who speak a language other than English, are less likely to seek out mental health services (when they need them) than Australian-born or English-speaking immigrants (Gou, 2020; Hiscock, 2020). Children and families from non-English-speaking CALD backgrounds face service barriers, including:

• difficulties navigating complex or fragmented services
• language barriers and inadequate interpretation services
• cultural misunderstandings; and
• implicit bias in practitioners.

These challenges can lead to dissatisfaction with or mistrust of services (Hiscock, 2020; Guo et al., 2020).

Although children and families from CALD backgrounds are less likely than people from non-CALD populations to use formal or clinical mental health services, it does not mean they have fewer mental health difficulties or do not wish to seek support. There is, for example, some evidence to suggest a growth in telephone or remote support use by children from CALD backgrounds (Yourtown, 2020). Children from refugee and asylum seeker backgrounds are also likely to have been exposed to traumatic experiences (Henley & Robinson, 2011). Findings from Building a New Life in Australia, a longitudinal study of resettled humanitarian migrants and their families in Australia, showed that some children had poorer mental health outcomes compared to the Australian age-matched community data (Lau, 2018).

Mental health concerns in CALD children may also present differently than in non-CALD children. For example, children from CALD backgrounds may have more emotional and internalising difficulties (e.g. depression, anxiety), which can be difficult to identify (Hiscock et al., 2020; Terhaag, Fitzsimons, Daraganova, & Patalay, 2021). Parents from CALD backgrounds may also have different considerations for seeking help than parents from non-CALD backgrounds. They may, for example, seek support for health concerns such as Autism Spectrum Disorder (ASD), but may consider emotional difficulties to be ‘normal’ behaviour (Basu & Isaacs, 2019; Hiscock et al., 2020).

There is limited Australian research on what works to support the mental health of children from CALD communities. However, many Australian multicultural, mental health and peak bodies consider culturally responsive practice to be critical for creating recovery-oriented and safe mental health service delivery for CALD communities (MHiMA, 2014). Several of these peak bodies have published best-practice guidance on culturally responsive practice (summarised in Table 1). Taking the time to engage with culturally responsive training will help practitioners and organisations to create culturally responsive services.

Table 1: Australian resources to support organisations and practitioners to adopt culturally responsive practice

This section is designed to help you to reflect on when, and how, services can be culturally responsive. We suggest reading the following case study, then downloading and completing the accompanying worksheet.

Meet Imani

This fictional case study explores everyday experiences of children and families from CALD backgrounds and their interactions with health systems.

Imani is an eight-year-old Australian girl with an Indian heritage. Her parents migrated from India to Australia before she was born. Imani has been at the same school since she was in kindergarten. Lately, she has been complaining of stomach aches, so her mother, Shankari takes her to see the GP at the local medical centre.

Shankari is relieved to hear that Imani shows no signs of physical health problems. The GP asks more questions about Imani and her school. Shankari believes that Imani likes the school and has friends. She has had no complaints from the school about Imani’s behaviour, and Imani is performing well academically. However, when the GP asks Imani about school, Imani looks down at her feet and shrugs. The GP provides Shankari with some information about child mental health and suggests that seeing a mental health counsellor would be helpful for Imani.

Imani and her mother walk away from the appointment with a referral to a counsellor, but both are still unsure about the GP’s recommendation. Despite her doubts, Shankari tries to book an appointment for her daughter. Appointments are only available during the day and the clinic is far from their home. Going would mean taking Imani out of school and driving her to the appointment. However, the family only has one car, which Imani’s father needs for work.

In our review of the evidence, we identified a series of common features and themes of culturally inclusive and responsive practice and services. Under each theme, practical considerations are provided to support implementation.

These themes consider both systems/organisational and individual practitioner implications. However, they do not cover all aspects of cultural responsiveness. When applying this information to your work, we recommend working through the resources outlined in Table 1 to encourage further learning and reflection.

Build cultural responsiveness into governance, accountability and evaluation initiatives

• Build cultural responsiveness into organisational performance measures. An example of this is assessing and measuring cultural responsiveness as a key outcome in your program planning.
• Include learning about the local CALD demographics and community needs as part of your service/program needs assessments.
• At the local practice level, collecting data disaggregated by ethnicity can help identify gaps in services.

For more guidance refer to: MHiMA’s workforce implementation guide; Ethnic Communities Council of Victoria’s recommendations (section 5, pp. 15–18); Embrace Framework (service modules one and two).

Include community participation and co-design in organisational planning and service provision

• Include lived experience in service planning and provision. This should include proactively seeking out the voices of children and families from CALD backgrounds. This process is likely to be needed for your organisation to build partnerships with local community or ethno-specific organisations, including faith-based community leaders.
• Provide multiple avenues for obtaining feedback from clients with CALD backgrounds (e.g. a combination of written and verbal feedback).
• Find ways to embed your practice/service within CALD communities, for example by having a presence at local community events. This can build trust and help to reduce stigma for those accessing mental health services.
• Engage with bicultural workers and cultural peer support services to support your work with people from CALD communities.

For more guidance refer to: Ethnic Communities Council of Victoria’s recommendations (section 5, pp. 15–18); Embrace Framework (service module three).

Understand how cultural beliefs and values affect perceptions and understanding of mental health and service systems

• Language and framing matter. Commonly used ways of talking about mental health can be alienating for families from CALD backgrounds, so consider using terms that families will relate to. For example, instead of using medical terms or ‘mental health’, you could ask about the child’s happiness and ‘social and emotional wellbeing’, and if they feel safe.
• Listen to the language that families use and, where appropriate, mirror how the family talks about the child’s mental health.
• Be curious about other languages and discuss language diversity as a strength, rather than seeing a lack of English proficiency as a deficiency. Provide information in multiple languages and discuss whether an interpreter is needed early in the process. Ensure the interpreter is trustworthy and culturally appropriate (i.e. the appropriate gender, age, and ethnicity for the client).
• Consider what support the family may need in navigating the mental health service system. People who have not previously accessed mental health services may not know the role of different practitioners (e.g. social worker, counsellor or psychologist) and what they can disclose in conversation. Families may also need help familiarising themselves with mental health terminology and how to navigate the service landscape in Australia.

For more guidance, refer to the Embrace Framework (service modules one and two).

Build flexibility and adaptability into service provision

• Provide multiple options for CALD children to ask for support. For example, anonymous online or phone services may give children from CALD communities the confidence to connect with services.
• A CALD family may need practitioners to be proactive in coordinating care (e.g. organising appointments and interpreters and conducting follow-up phone calls with families). Families may also need time to build rapport. This may require practitioners and service providers to spend more time with some clients but could be necessary to provide adequate and equitable service.
• Practitioner continuity can help build rapport and help detect mental health or developmental challenges early. For example, a child’s regular practitioner (such as a GP or other healthcare professional) can be more likely to notice changes in the child’s usual behaviour that may indicate early signs of difficulties.

For more guidance refer to: Embrace Framework (service module two); Mental Health in Multicultural Australia Framework (key concept three, pp. 34–36).

An understanding of culture, personal biases and practicing cultural curiosity

• Think about how your personal, professional and organisational cultures influence your interactions with children and their families.
• Think about how each child and family will have unique cultural identities and may hold multiple social identities.
• Be open to alternative ways of supporting mental health, based on what the family tells you.

For more guidance, refer to: Victorian Transcultural Mental Health’s orientation to cultural responsiveness training; Emerging Minds’ practicing cultural curiosity guide.

Culturally responsive practice is important to support the mental health of children from CALD backgrounds and can help reduce barriers to service use. This resource outlines actionable strategies for services and organisations to ensure their work is more culturally responsive and provides reflective prompts for practitioners. We also have a separate resource on supporting child mental health in refugee and asylum seeker populations, which describes the importance of working in trauma-informed ways.

More research and evaluation will help identify which approaches to cultural responsiveness are most effective for improving mental health outcomes for children from CALD backgrounds, including how best to implement them. However, the frameworks, guides, training and research outlined in this resource can help services and practitioners implement culturally responsive best practice.

Further resources

Practicing cultural curiosity when engaging with families practice paper (Emerging Minds)

Reflections on culturally competent practice with Mthobeli Ncganga podcast (Emerging Minds)

Reflections on culturally competent practice with Nellie Anderson podcast (Emerging Minds)

How the experiences and circumstances of culturally and linguistically diverse (CALD) children and families influence child mental health practice paper (Emerging Minds and the Australian Institute of Family Studies)

Culturally informed ways to support mental health in refugee and asylum seeker children practice paper (Emerging Minds and the Australian Institute of Family Studies)  

Approaches to support child mental health in culturally and linguistically diverse communities webinar  (Emerging Minds and the Australian Institute of Family Studies)  

Cultural considerations to support children from migrant and refugee backgrounds webinar (Australian Institute of Family Studies and Emerging Minds)  

Understanding the mental health and help-seeking behaviours of refugees short article (Australian Institute of Family Studies)

Working with interpreters toolkit (Victorian Transcultural Mental Health)

References

Australian Bureau of Statistics. (2022). Snapshot of Australia: Culturally and linguistically diverse communities. Canberra, ACT: ABS.

Basu, S., & Isaacs, A. N. (2019). Profile of transcultural patients in a regional Child and Adolescent Mental Health Service in Gippsland, Australia: The need for a multidimensional understanding of the complexities. International Journal of Social Psychiatry, 65(3), 217–224.

Dolman, C., Ngcanga, M., & Anderson, N. (2020). Practicing cultural curiosity when engaging with children and families. Adelaide, South Australia: Emerging Minds.

Embrace Multicultural Mental Health. (2016). Embrace Multicultural Mental Health Framework for Mental Health in Multicultural Australia: Towards culturally inclusive service delivery. Canberra, ACT: Embrace, Multicultural Mental Health.

Ethnic Communities Council of Victoria (ECCV) (2021). Recommendations for a culturally responsive mental health system. Melbourne, VIC: ECCV.

Federation of Ethnic Communities’ Councils of Australia. (2020). If we don’t count it… it doesn’t count: Towards consistent national data collection and reporting on cultural, ethnic and linguistic diversity. Canberra, ACT: FECCA.

Guo, S., Liu, M., Chong, S. Y., Zendarski, N., Molloy, C., Quach, J. … O’Connor, M. (2020). Health service utilisation and unmet healthcare needs of Australian children from immigrant families: A population‐based cohort study. Health & Social Care in the Community, 28(6), 2331–2342. doi:10.1111/hsc.13054

Hiscock, H., Mulraney, M., Efron, D., Freed, G., Coghill, D., Sciberras, E., … Sawyer, M. (2020). Use and predictors of health services among Australian children with mental health problems: A national prospective study. Australian Journal of Psychology, 72(1), 31–40.

Lau, W., Silove, D., Edwards, B., Forbes, D., Bryant, R., McFarlane, A., … O’Donnell, M. (2018). Adjustment of refugee children and adolescents in Australia: outcomes from wave three of the Building a New Life in Australia study. BMC Medicine, 16(1), 1–17.

Mental Health in Multicultural Australia (MHiMA). (2014). Framework for Mental Health in Multicultural Australia: Introductory Guide. Macgregor, QLD: MHiMA.

Mental Health in Multicultural Australia (MHiMA). (2014). Framework for Mental Health in Multicultural Australia: Workforce Implementation Guide: Key outcome areas. Macgregor, QLD: MHiMA.

Nguyen, H. T., Connelly, L. B., Le, H. T., Mitrou, S., Taylor, C. L., & Zubrick, S. R. (2019). Sources of ethnicity differences in non-cognitive development in children and adolescents. Life Course Centre Working Paper Series, 2019-21. Brisbane, QLD: Institute for Social Science Research, The University of Queensland.

Queensland Transcultural Mental Health Centre Training (last updated 2021). Cultural considerations in Mental Health Assessment. Woolloongabba, QLD: Queensland Transcultural Mental health Centre.

Terhaag, S., Fitzsimons, E., Daraganova, G., & Patalay, P. (2021). Sex, ethnic and socioeconomic inequalities and trajectories in child and adolescent mental health in Australia and the UK: Findings from national prospective longitudinal studies. Journal of Child Psychology and Psychiatry, 62(10), 1255–1267.

Victorian Transcultural Mental Health (VTMH). (2015). Cultural responsiveness principles & practices [Online course]. Melbourne: VTMH.

yourtown. (2020). Kids Helpline Insights 2020. Milton, QLD: yourtown.