Cultural Considerations

What is Culturally-Sensitive Trauma-Informed Care?

Culturally-Sensitive Trauma-Informed Care refers to the capacity for health care professionals to effectually provide trauma-informed assessment and intervention that acknowledges, respects, and integrates patients' and families' cultural values, beliefs, and practices.

Here, "culture" extends beyond the identification of a child and family's race and ethnicity to include other variables such as faith/religion, sexual orientation, region of residence, and level of acculturation, and closely related factors such as socioeconomic status and literacy level.

How does this complement culturally competent health care practice?

As in all pediatric care, Culturally-Sensitive Trauma-Informed Care requires attention to be paid to a child's and family's values and beliefs about health and illness. What's unique is that attention must also be paid to cultural variations in the child's and family's experience of and response to trauma.

Research suggests that although there is a universal biological response to trauma, cultural factors can influence the biopsychosocial experience of trauma and subsequent traumatic stress reactions. Ethnocultural factors play an important role in an individual's vulnerability to, and experience and expression of traumatic stress, as well as one's response to trauma treatment.

What are the key components of Culturally-Sensitive Trauma-Informed Care?

A culturally-sensitive, trauma-informed care provider can help traumatized children and families by:

How do I implement Culturally-Sensitive Trauma Informed Care?

Understanding perceptions of traumatic stress and the role of beliefs:

Research suggests that it is NOT the objective severity of the trauma, but how it is experienced by the child or parent that determines traumatic stress responses.

  • Cultural differences can exist in the perception and interpretation of the trauma event, the meaning given to the traumatic event and beliefs about control over the event.

Viewed through a cultural lens, a child's or family's subjective perceptions of the trauma experience can sometimes be quite different from a provider's.

  • For example, some cultures interpret illness and other trauma events as punishment, a test or rite of passage, or a special message.
  • The way a child or family interprets the meaning of the trauma will influence subsequent distress, reactions, and ways of coping.
  • Cultural differences can also exist in beliefs about if, when, and how to resolve traumatic stress symptoms, and about help-seeking and utilization of supportive resources outside their community
  • Remembering that some interpretations may differ from your own, it is best to ask children and families about what the trauma means to them, and incorporate those beliefs into assessment and treatment.

Back to Top

Restoring safety and re-establishing trust:

Trauma erodes a child's or family's sense of physical and emotional safety; promoting trust rebuilds it.

  • When a trauma occurs, children's and families' global beliefs about safety, vulnerability, responsibility, control, and appropriate ways of coping play a significant role regarding how the trauma impacts them.
  • Initially, many traumatized children and families can feel physically unsafe and emotionally vulnerable; they may have a difficult time trusting others or accepting help as a result.
  • Viewed through a cultural lens, some groups are less likely to trust health care providers with the details of the trauma, their symptoms, or treatment recommendations.
  • In these instances, providers should take a step back to assess how their helping role is perceived. Providers should also try to connect the family with resources they trust – including other types of professionals and traditional healers.

Safety and trust is established not only through words, but through actions.

  • Providers' cultural awareness and sensitivity help to create provider-patient interactions that build trust and promote optimal patient communication and adherence.
  • Beyond the words providers choose, some cultures are highly sensitive to nonverbal communication – including eye contact, tone of voice, facial expressions, body language and touch.
  • Culturally appropriate communication practices have been shown to result in higher levels of perceived trust and increased reporting of information.

Back to Top

Attending to distress:

Significant cultural variations exist in a child's or family's expression of distress.

  • Pain, fear, worry, or hyperarousal are sometimes expressed somatically. Traumatic stress reactions can be extremely subdued, can appear to be over-magnified, or can even mimic psychotic reactions. Often, family and cultural factors combine to define what is considered an appropriate reaction to illness or trauma.
  • Some families and cultural groups are less comfortable responding to personal questions about emotional distress. They may think that being distressed means that there is something mentally wrong.
  • What providers can do:
    • Provide psychoeducation about common, universal reactions to trauma.
    • Understand emotional reactions by asking about and responding to specific behaviors (sleep and eating patterns, jitters, etc.).
    • Listen to and incorporate the child's or family own terms for what they are experiencing into discussions and treatment planning.

Back to Top

Working within and through the family structure:

Some families and cultural groups have distinct customs about who makes decisions and how they are communicated.

  • These customs may lead to limitations on the child's or other family members' involvement in discussions and decisions.
  • Incorporating extended family and kinship networks, as well as other types of healing professionals and practices that the child and family view as helpful, may positively impact assessment and treatment.

Back to Top

Considerations in providing Culturally-Sensitive Trauma-Informed Care

What considerations should I keep in mind in providing Culturally-Sensitive Trauma-Informed Care?

View RELATIONSHIPS through a Culturally-Sensitive Trauma-Informed lens

  • Understand your role as a provider within this family's world.
  • Gain a better understanding of the roles and dynamics within this family.
  • Consider and facilitate the inclusion of others (extended family, clergy, healers) when treating patients.

View ASSESSMENT through a Culturally-Sensitive Trauma-Informed lens

  • The manifestation and expression of psychological states differ depending on personal, familial, and cultural beliefs and practices.
  • Listen to and use the family's own terms during assessment and treatment planning
  • Trust in / comfort with the provider has been shown to be associated with increases in patient disclosure in some cultural groups.

View TREATMENT through a Culturally-Sensitive Trauma-Informed lens

  • Healing comes in many different forms; your ideas, beliefs, and values may differ from the family's.
  • Be sure you have integrated the family's understanding of diagnosis, prognosis, and healing into your treatment planning.
  • Consider each family's resources and barriers to help-seeking and utilization of supportive services within the community.

Back to Top

Implementing Culturally-Sensitive Trauma- Informed Care with patients

How do I implement Culturally-Sensitive Trauma-Informed Care in my own patient interactions?

Culturally-sensitive care begins with the provider

  • CPTS designed the D-E-F protocol as a practical tool to guide health care providers in implementing trauma-informed pediatric care.
  • The cultural considerations component of the D-E-F protocol helps providers implement trauma informed care in a culturally-sensitive manner that considers a child and family's unique cultural beliefs, values, and practices.
D-E-F: Guide to Culturally-Sensitive Trauma-Informed Care D-E-F: Providing Culturally-Sensitive Trauma-Informed Care

Additional Resources:

The National Child Traumatic Stress Network (NCTSN) website features various resources related to culture and trauma.

The National Center for PTSD (NCPTSD) website features a course module entitled PTSD: General Cross-Cultural Considerations.

Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches: Field Report. Retrieved from www.commonwealthfund.org.

Davidhizar, R. (1999). Assessing culturally diverse pediatric clients. Pediatric Nursing, 25(4), 371-376.

Marsella, A. J., Friedman, M. J., Gerrity, E. T., & Scurfield, R. M. (1996). Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical applications. Washington, D.C.: American Psychological Association.

Back to Top

 

Cultural Considerations

Getting a better understanding of children's and families' beliefs about the cause and meaning of trauma and traumatic stress symptoms, and integrating them into care, can enhance culturally-sensitive trauma-informed assessment and intervention.

Culturally Competent Pediatric Trauma Care

Although there is a universal biological response to trauma, cultural factors can influence the biopsychosocial experience of trauma and subsequent traumatic stress reactions. Ethnocultural factors play an important role in children's and families':

  • Vulnerability to trauma and traumatic stress
  • Expression of distress and trauma symptoms
  • Response to trauma treatment
  • Help-seeking behaviors
  • Communication with and between family members
  • Willingness to disclose psychosocial information to providers

In providing culturally competent trauma care, health care providers should:

  • Recognize the cultural variations in the perception of trauma and traumatic stress responses.
  • Ask children and families about what the trauma means to them, and incorporate these beliefs in assessment and treatment.
  • Listen to and integrate the child or family's own terms for what they are experiencing.
  • Understand how your helping role is perceived and family dynamics and decision-making.
  • Be open to including kinship networks and other types of healing professionals or practices that the family views as helpful.
  • Remember and respect that some children's and families' interpretations, experiences, and practices my differ from your own.

The cultural considerations component of the D-E-F protocol helps providers implement culturally competent pediatric trauma care in a manner that considers a child and family's unique cultural beliefs, values, and practices.

Download D-E-F Pocket Cards with quick screening and intervention recommendations.

D-E-F: Guide to Culturally-Sensitive Trauma-Informed Care

D-E-F: Providing Culturally-Sensitive Trauma-Informed Care

Order Provider Materials

Coming Soon