Considerations for adapting a group CBT anger coping program to Native American school populations
By Jeffrey D. Shahidullah
There is a critical need for evidence-based mental health interventions for American Indian and Native American (AI/NA) youth as myriad risk factors in this population increase the likelihood for antisocial behavior and disruptive behavior disorders. With the paucity of empirical studies focused on addressing problem solving for coping skills in AI/NA schoolchildren, there is a need for the selection and adaptation of existing evidence-based anger coping interventions to be implemented and rigorously researched. One research-based school intervention for angry and aggressive behaviors is the Anger Coping Program (ACP; Larson & Lochman, 2011). This paper explores considerations for a culturally-adapted ACP to be delivered in AI/NA schools. First, the unique needs of the target population are examined and juxtaposed with the specific methods and goals of ACP. Next, the research evidence for ACPs effectiveness on both the standardized population as well as for use with diverse populations is provided. Finally, an overview of the necessary adaptations, as put forth by the empirical literature is provided. Taken together this analysis of an adapted-ACP for use with AI/NA school children, may inform future research and practice in the intervention of angry and aggressive behaviors in a clinically-indicated, yet traditionally underserved population.
Keywords: American Indian youth, Native American youth, mental health interventions, anger, school
There is a critical need for evidence-based mental health interventions for American Indian and Native American (herein referred to as AI/NA) school children as myriad risk factors in these populations increase the likelihood for antisocial behavior and disruptive behavior disorders (Dicken & Rutherford, 2005; Whitbeck, Yu, Johnson, Hoyt, & Walls, 2008). With the exception of a notable few (e.g., Families and Schools Together [FAST]; Kratochwill, McDonald, Levin, Bear-Tibbetts, & Demaray, 2004; First Step to Success; Walker, Stiller, Golly, Kavanagh, Severson, & Feil, 1997), empirical studies focusing primarily on addressing problem solving for coping skills conducted with AI/NA school children are nonexistent. The majority of evidence-based interventions for AI/NA youth are focused primarily on substance abuse and suicide prevention (Jackson & Hodge, 2010). There is a clear need for the selection and adaptation of existing evidence-based anger coping interventions to be implemented and rigorously researched in AI/NA school populations. One research-based school intervention for angry and aggressive behaviors is the Anger Coping Program (ACP; Larson & Lochman, 2011). ACP is a group-based, cognitive-behavioral intervention that addresses key deficits that children display in effectively coping with anger through developing physiological and emotional awareness and fostering social problem-solving skills, perspective taking and attribution retraining (Lochman, Nelson, & Sims, 1981).
This paper explores considerations for a culturally-adapted ACP to be delivered in AI/NA schools. First, the unique needs of the target population are examined and juxtaposed with the specific methods and goals of ACP. Next, the research evidence for ACPs effectiveness on both the standardized population as well as for use with diverse populations is provided. Finally, an overview of the necessary adaptations, as put forth by the empirical literature is provided. Taken together this analysis of an adapted-ACP for use with AI/NA school children, may inform future research and practice in the intervention of angry and aggressive behaviors in a clinically-indicated, yet traditionally underserved population.
Meeting needs of AI/NA youth
Despite a paucity of mental health and intervention research in AI/NA youth, the existing data provides cause for alarm. While most research looks at the increased rate of alcohol abuse and suicide in AI/NA youth (May & Moran, 1995), other research clearly shows that mental health disorders are associated with these problems (Beals et al., 1997). Additionally, depression and conduct disorder are indicated risk factors for these negative outcomes (Dinges & Doung-Tran, 1993; Grossman, Milligan, & Deyo, 1991). The prevalence of anger and aggression in AI/NA youth supports the need for early and effective intervention. Without effective coping strategies, youth often rely on maladaptive practices such as substance use to mask these angry feelings. Also, without early intervention, these angry and aggressive behaviors in childhood may likely form into violent and other aggressive acts such domestic violence, which Fletcher (2009) describes as an “epidemic” in AI/NA populations, and suicide. The alarming rate of suicide stands as the most striking single indicator of the need for effective mental health service delivery for this population. The suicide rate of AI/NA male youth is 2 to 3 times higher than that of the general population (Mock, Grossman, Mulder, Stewart, & Koepsall, 1996).
There are a number of other striking risk factors that exacerbate the problems of AI/NA youth such as their being the most impoverished minority group in the United States, being overrepresented among people who are homeless, coming from families with members who are incarcerated, high rates of being in foster care, coming from families with substance addictions, and subsequently high birth rates with fetal alcohol syndrome, fetal alcohol effects, cognitive impairments, and a host of other health impairments (U.S. Department of Health and Human Services [USDHHS], 2001). Despite the overwhelming level of indicated mental health needs, these populations are traditionally underserved as a result of a lack of access to effective providers and a lack of empirically-supported treatments for use in AI/NA youth. With the appropriate adaptations and implementation procedures it appears that ACP can potentially be a helpful intervention for intervening with early aggressive behaviors, which is a risk factor for early substance abuse, a demonstrated problem in many AI//NA populations (Coie, Terry, Zakriski, & Lochman, 1995; Lochman & Wayland, 1994). Integrating this empirically-supported intervention into the cultural context of an AI/NA school can be the necessary first step in measuring its effectiveness for use in this population of youth.
Anger coping program description
The Anger Coping Program is a cognitive-behavioral counseling intervention designed to meet the needs of students in grades 3-7 through pull-out small-group skills training over 18 weekly sessions. Typically, it is used in the context of a Level 2 response to intervention (RTI) or positive behavioral intervention and supports (PBIS) framework (selected prevention measures) for children that have been unresponsive to both Level 1 universal supports and Level 2 classroom-based behavioral supports. Specifically, it addresses students with problematic levels of anger and aggressive behavior which disrupt the safety and learning environment for themselves and peers.
Conceptualization of mental health
Angry and aggressive students often demonstrate a variety of deficits or distortions in their processing of social information, thus contributing to difficulties in social competence (Lochman & Wells, 1996). ACP was developed from the social information-processing model (i.e., social cognitive model) developed by Crick and Dodge (1994) which emphasizes the role of cognition in how children process social information within six sequential steps: (1) encoding social cues, (2) interpreting these cues, (3) identifying social goals, (4) generating possible solutions to the perceived problem, (5) evaluating these solutions, and (6) enacting the chosen solution. Research indicates that aggressive children display difficulties at the first two steps (i.e., cognitive processing of the problem event) and steps 4 and 5 (i.e., cognitive processing of the responses) (Larson & Lochman, 2011). These processing deficits (i.e., cognitive distortions) often result in selectively recalling and attending to hostile rather than neutral interpersonal cues (Gouze, 1987; Milich & Dodge, 1984). These misinterpreted cues often elicit hostile attribution biases, whereby students under-perceive their own situational influence, aggressive behaviors, and responsibility for conflict (Guerra & Slaby, 1989) and over-perceive the aggressive actions of others. This social cognitive model of anger arousal provides the empirical foundation for understanding angry and aggressive behaviors in youth (Lochman, Powell, Whidby, & Fitzgerald, 2006). It is theorized that the group setting is most effective for intervening in these types of emotional and behavioral responses by 1) allowing children to receive peer feedback, 2) providing in-vivo experiential learning, and 3) increasing the likelihood of skill generalization (Lochman, Burch, Curry, & Lampron, 1984).
Methods and goals
ACPs social-cognitive framework stresses the importance of the initial appraisal of the problem situation, problem solutions, elicited physiological arousal, and the behavioral response. The goal of ACP is to demonstrate the role that labeling emotions, thought processes, and schemas can have in determining what student’s process. It accomplishes this by facilitating anger management, physiological, and emotional awareness, perspective training and attribution retraining, and social problem solving.
The groups are co-led by a trained teacher, counselor, and/or school psychologist in the school setting. Weekly sessions of roughly 45 minutes focus on teaching the principles of individual perceptual processes. Additionally, each session incorporates goal setting, role playing, video modeling, practicing effective problem-solving strategies, exploring self-statements, recognizing early signs of emotional and physiological anger arousal, generation of possible solutions, linking choices with consequences, intervening in anger arousal through self-talk, relaxation, distraction strategies, discussions, and debriefing. The ACP utilizes a contingency-based reward system to facilitate participation and involvement. Teachers and school staff are actively involved in the goal setting process and are expected to look for and reinforce pro-social behaviors that ACP participants develop. Additionally, teachers provide weekly feedback and progress updates to inform the intervention content and the emphasis of weekly sessions.
Cognitive problem-solving skills training has been labeled a “promising treatment” for children with externalizing behavior problems as it has shown significant improvement in reductions of aggressive and antisocial behavior (Kazdin & Weisz, 1998). Results from two task forces on effective psychosocial interventions, Brestan and Eyberg (1998) and Eyberg, Nelson, and Boggs (2008) found that ACP was a promising cognitive-behavioral intervention for children with angry and aggressive behaviors. Further, in a meta-analysis of anger management programs for school age youth, Smith, Larson, DeBaryshe, and Salzman (2000) concluded that ACP was among the few programs possessing both strong design and empirical evidence.
Thus far, ACP has been implemented and evaluated in samples of predominantly Caucasian and African American youth, and within these samples, the results of efficacy and effectiveness research have not found race as a moderating variable (Larson & Lochman, 2011). This suggests that the underlying source of change (e.g., social cognitive factors) in which ACP is grounded is similar across these groups.
Of course, no matter how effective ACP appears to be, implementers must always use caution when endorsing interventions that have not been tested in certain populations. For example, the cognitive-behavioral orientation of ACP may be subject to specific cultural restraints (e.g., SES, race, cultural context) as Lochman, Whidby, and Fitzgerald (2000) indicate that cognitive-behavioral approaches that aim to change social cognitive deficits and distortions in aggressive children and adolescents may be less effective in certain cultural backgrounds.
While research on AI/NA school children are largely missing from the research database, the existing research with these youth using cognitive-behavioral approaches (Schinke, Tepavac, & Cole, 2000) and focusing on problem-solving skills through a social cognitive orientation (LaFromboise & Howard-Pitney, 1995) reveal that these youth engage in and benefit from these interventions when they are offered in the school. For example, Diken and Rutherford (2005) implemented First Step to Success (Walker et al., 1997) with four Native American school children to address early onset antisocial behavior and found that it had a significant positive effect on student’s social play behaviors, while decreasing nonsocial behaviors.
Similar studies are needed to evaluate ACPs effectiveness in this population as small scale implementation and evaluation within reservation-based schools may be a critical first step in obtaining preliminary data to inform and provide necessary adaptations for future interventions. While many tribal groups will be assimilated into mainstream culture and be comfortable with the standardized intervention, others will hold more traditional views to healing. Therefore, ACPs use in specific AI/NA groups will not garner the empirical support for its widespread use in all AI/NA groups as the success of each implementation will likely vary according to the acculturation of each group. To account for the varied levels of acculturation and views toward healing, unique cultural adaptations may be needed with each implementation.
Adapting to the needs of AI/NA populations
In the following sections we discuss the need for cultural adaptations in AI/NA populations in general without listing concrete examples as vast heterogeneity exists among various tribal groups. Effective mental health interventions for use in this population must be provided in the cultural and ecological context of AI/NAs nuanced therapeutic paradigms. Because various AI/NA cultures are unique, specific adaptations will require close collaboration with local community partners for effective and efficient development and integration. Close collaboration with tribal or community stakeholders will help intervention developers acknowledge that needs will be unique based upon the tribe, community, and school, and so, it is important to assess these unique needs through focus groups with the target population and key community stakeholders to understand unique risk and protective factors.
To determine what, if any, adaptations should be made, it is helpful to utilize an intervention adaptation process framework. In drawing from Rogers’ (2000) diffusions of innovations framework, Domenech, Rodriguez, and Wieling (2004) outline a three-phase Cultural Adaptation Process Model. Phase one involves determining the needs of the community through a collaborative process with key community leaders. Phase two involves the selection and adaptation of evaluation measures, soliciting input from community members, and pilot testing. Phase three integrates the lessons learned from the previous phase into a revised intervention through continued collaboration with community stakeholders. By identifying and utilizing local topical experts to assist in the adaptation, intervention developers attempt to appropriately incorporate cultural changes to the surface structure (and possibly deep structure), while maintaining fidelity to core elements.
Considerations based on evidence from the AI/NA literature
Motivation for change
A primary moderating variable in the potential success of this intervention will be the level of acculturation the group has to the dominant culture. For many Indian groups, the intervention format using social-cognitive principles, group discussions, and sharing may not be the most effective as participants may question their own abilities to facilitate change. For example, DuBray (1992) explains the endorsement of a “being” rather than a “doing” philosophy of life. This “doing” philosophy assumes that individuals’ ability to change is predicated on the achievement of measurable standards perceived to be external to the scope of influence that an individual has. Therefore, many AI/NAs ascribe to a “being” philosophy of life whereby circumstances are inherently predetermined and in which an individual has limited control over a host of external determinants. The pressures of “doing” in order to align with expectations of a school code of conduct or population-based mental health or behavioral initiative, may be incongruent with cultural views. Also, in many AI/NA cultures, such as that of the Navajo, AI/NAs emphasis on the sequence of time is present, past, and future, in that order. For these individuals, plans are not made for the future as the belief is that this domain is out of one’s control, and so, to plan as if one has the ability to alter, change, or predict the future is futile (Purnell & Paulanka, 2005).
Cultural styles of expression
The intervention implementers must be sensitive to cultural styles of expression in order to avoid miscommunications. As AI/NAs typically do not share inner feelings with those outside their group, tribe, or clan, it may take the interventionist extra time to build rapport and trust (Purnell & Paulanka, 2005). Also, it is important to consider that preferred manners and behavioral expectations are often modeled by parents at an early age without extensive verbal communication (DuBray, 1993). This reliance on non-verbal signals is often permeated through the culture from indicating approval or disapproval from parents or teachers. Developing the focus on understanding AI students through body language can not only inform the content of focus within intervention, but also indicate participant’s acceptance of or resistance to the proposed intervention (Sue & Sue, 1990). ACPs focus on understanding nonverbal signals may make it conducive to use in this group. Also, ACPs flexibility in implementation and program design make it amenable to varied participant groups. With familiarity of the manual, group leaders are encouraged to use their clinical judgment when making cultural adaptations. Rather than the use of “scripts” that explicitly dictate what leaders should say or participants should do, the use of general objectives and training guidelines allow ACP to be individualized to fit the needs of the group.
Individual and collective strengths of native community
It is important to not focus solely on the risk factors in this population, without fully acknowledging the unique protective factors of the AI/NA community (e.g., collectivistic, resiliency, orientation to nature, resourcefulness, wisdom of family/tribal leaders). By noting these factors it can facilitate the process of developing a strengths-based approach in order to integrate these principles into the intervention plan. Given the collectivistic family and community orientation that many AI/NA groups possess, an empirically-supported approach used in many mental health service deliveries to AI/NAs is family-systems theory (DuBray & Sanders, 1999). The premise of this theory is that the entire family structure is intimately connected with interplay between factors that affect one individual reverberating to the entire family. It recognizes the view that the child is a critical component of this interrelateled system. Problems in school and with ineffectively managing angry and aggressive impulses will not only lead to future maladaptive outcomes but will negative affect the entire family. Obtaining buy-in from the family may likely dictate the willingness of the child to succeed in ACP.
Contribution of traditional healing practices
For interventions to be successful, Western-based mental health practices must be integrated into the culture rather than the reverse (adding culture to the EBP). LaFramboise, Trimble, and Mohatt (1990) espoused the importance of providing culturally competent mental health interventions to these populations by recognizing, respecting, and facilitating the integration of “traditional treatments” with conventional psychotherapeutic services in a manner that is theoretically aligned with Native traditions. Because of AI/NAs emphasis on spirituality, an adapted intervention approach that blends elements of mind, body, and spirit may be necessary and contribute to a holistic approach to intervention. An expert panel from the IHS/SAMHSA National Behavioral Health Conference on American Indian and Alaska Native Best Practices in Behavioral Health (2008) put forth the following summative recommendations: community accepted healing approaches; evaluation of the practice-based evidence and “certification” of the provider by the community; honor family choice for support system, spiritual, extended family, tribal, IHS, or mainstream programs and churches for increased anonymity; staff training to emphasize strength-based assessments & treatment planning & inclusion of cultural supports; and use of native language to reinforce value of wellness.
The social-cognitive model that guides the targeted goals for ACP provides an empirically strong framework, while also allowing the flexibility for adaptations needed to address specific cognitive-deficits and strengths of particular populations. Though the utility and transportability of ACP into a rural Native American school for use with angry and aggressive children is highly dependent on the participants’ level of acculturation to Western perspectives on mental health, ACP does appear promising. Its inherent focus on having multiple stakeholders involved is easily conducive to a family-systems approach whereby, the children’s families, communities, and local topical experts can have a voice in both the goals and format for intervention.
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About the Author
Jeffrey D. Shahidullah is a school psychology doctoral student at Michigan State University.