O

A
OUTSTANDING ACADEMIC PAPERS BY STUDENTS

P S

A collaborative, international program by academic research libraries to encourage, recognize, and preserve excellence in student scholarship

2010
USC LIBRARIES | USC SCHOOL OF SOCIAL WORK

UNIVERSITY OF SOUTHERN CALIFORNIA

OAPS
O U T S TA NDING AC A D E MIC PA P E R S BY S T U D E N TS
APRIL 2010
USC LIBRARIES USC SCHOOL OF SOCIAL WORK UNIVERSITY OF SOUTHERN CALIFORNIA

USC LIBRARIES USC SCHOOL OF SOCIAL WORK Published by Figueroa Press 840 Childs Way, 3rd Floor University of Southern California Los Angeles, CA 90089-2540 © 2010 USC Libraries All rights reserved No part of this book may be used or reproduced in any manner without written permission from the publisher, except in the context of reviews. ISBN-10: 1-932800-65-4 Library of Congress Control Number: 2010925616 Library of Congress Cataloging-in-Publication Data USC Libraries USC School of Social Work OAPS: Outstanding Academic Papers by Students

Contents
4 FOREWORD Catherine Quinlan 6 INTRODUCTION Marilyn Flynn 8 TRAUMA: A THEORETICAL PERSPECTIVE Amelia Abernathy 28 REVIEW OF THREE APPROACHES TO PLAY THERAPY: CHILD-CENTERED PLAY THERAPY, FILIAL THERAPY, AND SANDPLAY THERAPY Deborah Bauman 48 EVALUATION RESEARCH DESIGN IN THE IMMIGRANTS’ RIGHTS PROJECT Erin Dowler 66 CONCEPTUALIZING PEDOPHILIA THROUGH THEORY, NEUROBIOLOGY, AND CULTURE Jennifer Gebauer 90 CROSS-CULTURAL SKILLS BUILDING TRAINING PROGRAM FOR THE PROGRAM FOR TORTURE VICTIMS CLINICAL STAFF

Lorene Gingerich
116 SUCCESSFUL AGING AND ITS IMPLICATIONS FOR CHINESE COMMUNITIES Sarah Jacobus 128 SOCIAL WORK AND THE PATIENT-CENTERED MEDICAL HOME

Carolina Rodriguez
142 HEAD START AND DCFS Heather Stephens 156 POLICY ANALYSIS OF THE GANG VIOLENCE AND JUVENILE CRIME PREVENTION ACT Iman A. Turner 168 CHILDHOOD OBESITY IN AMERICA Krystal Wang

Foreword
CATHERINE QUINLAN
Dean, USC Libraries

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The Outstanding Academic Papers by Students (OAPS) program showcases excellent student research on a global stage and underscores the library’s role in the achievements of scholars-in-training. USC is the first North American institution to participate in this international endeavor with 11 Asian universities. We are very proud to present these ambitious explorations by USC School of Social Work students in our inaugural OAPS publication. Research libraries are necessarily global entities. In order to help our university communities achieve their goals, we develop collections that are as international as they are interdisciplinary. We build digital libraries that reach beyond the oceans and across the continents. We welcome researchers from nations far and wide to our home campuses, where treasures unique to each of our libraries inform the creation of new knowledge. As we help our students become citizens of the world, libraries must be increasingly collaborative keepers and effective communicators of the global body of knowledge. OAPS is one expression of that imperative. The USC School of Social Work—through its China Program, the Center for Asian-Pacific Leadership, and Global Immersion initiatives—prepares students for successful practice and leadership on an international scale. With such an expansive, international vision, the school is an exemplary partner in this project of cross-cultural exchange and understanding. I thank Dean Marilyn Flynn and the students and faculty of the School of Social Work for joining the USC Libraries as we introduce OAPS to the University of Southern California. I also would like to express my great appreciation to Professor Steve Ching, university librarian of the City University of Hong Kong, who began OAPS in 2005. Under his energetic leadership, it has become an emblem of vital collaboration among research libraries. As we look to expand OAPS to other schools at USC, I hope we are as successful as Professor Ching has been in inspiring participation in this rewarding and prestigious program.

Introduction
Dean and Professor, USC School of Social Work

MARILYN FLYNN

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It is with great pleasure that I present the University of Southern California School of Social Work’s inaugural collection of Outstanding Academic Papers by Students (OAPS) in partnership with USC Libraries. The USC School of Social Work is honored to partner with USC Libraries as the first North American university in this prestigious project and to be included with some of the finest academic institutions in Asia who are participants. Ten outstanding student papers were selected for publication in this collection by USC faculty and a review committee for their superior research, writing, and presentation. Faculty recommended papers based on their students’ exceptional ability to analyze and apply social work theories and their expertise in conceptualizing and pursuing their own evidence-based research. Recognition was given to papers that achieved excellence in scholarly output. The USC School of Social Work believes there is significant value in sharing these outstanding papers with international researchers and students along with our own students, faculty, administrators, and OAPS partner institutions. We hope other people can learn from this research and that it will enable them to better understand others’ diverse experiences and different cultures. The OAPS project aims to help students acquire proper research and writing skills and instill in them academic honesty and respect for intellectual property. It also provides an avenue for building a collection of distinguished student writing to share with partner institutions and to promote readership worldwide. The USC Libraries and USC School of Social Work collection includes term papers and projects, reports, case studies, and research from a diverse group of graduate courses. We believe this partnership is a great opportunity for our students to receive recognition and for the USC Libraries and the USC School of Social Work to highlight the quality of our students’ work. Not only does this partnership promote scholarly communications, but it allows online access to exceptional research papers from the USC community and other OAPS institutions. We are committed to OAPS’s goals and look forward to collaborating with other universities around the world to promote distinguished student papers.

Trauma: A Theoretical Perspective
AMELIA ABERNATHY
Human Development and Mental Health Professor Doni Whitsett

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INTRODUCTION

With the country still recovering from the devastating effects of Hurricane Katrina, as military personnel begin to return home from a war ignited by an act of terror, and while domestic violence and child abuse continue to persist, the concept of trauma is becoming increasingly pertinent to mental health professionals. Judith Herman (1992) describes psychological trauma as “an affliction of the powerless” (p. 33). Traumatic events can include everything from interpersonal violence to witnessing fellow soldiers die in an IED explosion. Cozolino (2002) argues that trauma can even include events such as separating from a parent (for a child) or loss of a pet (for an adult); trauma may even result from a stressed environment in utero. While these events may not be traumatizing for all individuals, mental health professionals must be aware of the extent to which events such as these can negatively impact a person’s overall functioning and well-being. In the following paper I will provide a description of trauma and its possible consequences. Next, I will explain trauma through three theoretical lenses: behavioral theory, cognitive theory, and neurobiological theory. Lastly, I will present cultural considerations when working with individuals coping with traumas and a brief treatment section on a widely used intervention for treating traumatized individuals.
TRAUMA AND THE TRAUMA RESPONSE

Trauma is the exposure to, or experience of, events that involve severe stressors (Basham, 2008) that overwhelm the individual’s capacity to adaptively function (Herman, 1992). Lenore Terr (1991) proposes two types of childhood trauma that assist in understanding the trauma response. Type I traumas include events such as rape, an earthquake, a car accident, witnessing death, and loss of a loved one (Basham, 2008). These are single, shocking and terrifying events in which the individual experiences symptoms that usually meet diagnostic criteria for Posttraumatic Stress Disorder (PTSD) (i.e. re-experiencing, avoidance, hyperarousal). Type II traumas, on the other hand, are traumas in which children have repeatedly been exposed to trauma. Child sexual or physical abuse and ongoing witnessing of domestic violence are examples of this. Reactions to this type

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of trauma involve rage, denial and psychic numbing, or self-hypnosis and dissociation (Terr, 1991). One may even argue that military personnel repeatedly exposed to death, mutilation, and possibly sexual assault may develop the same sense of learned helplessness that many children exposed to Type II traumas experience. While trauma may encompass a variety of reactions that involve a strain on one’s mental health, Westernized societies have come to understand trauma within the context of a clinical diagnosis—PTSD (Breslau, 2004).
The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, TextRevision (DSM-IV-TR) defines trauma within the anxiety disorder PTSD. PTSD defines

trauma as the exposure to an event in which: “(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” and “(2) the person’s response involved intense fear, helplessness, or horror” (American Psychological Association (APA), 2000, p. 467). There are three clusters of symptom criteria under which individuals diagnosed with PTSD must meet: re-experiencing (e.g. flashbacks, nightmares, intrusive thoughts), avoidance/numbing (e.g. avoidance of thoughts, places, or people reminiscent of the trauma, an inability to recall specifics of the traumatic event, restricted range of affect), and arousal (e.g. sleep difficulties, outbursts of anger, hypervigilance). The symptoms must be experienced for more than four weeks and must cause clinically significant disruption in functioning. A less severe disorder that may also develop in individuals who have been exposed to a traumatic event is Acute Stress Disorder (ASD) (APA, 2000). ASD shares a similar clinical picture to PTSD. However, the duration of symptoms is less than one month, and individuals must only meet three dissociative symptom criteria (e.g. lack of emotional response, depersonalization, and inability to access traumatic memory). It is important to keep in mind various diagnoses that may mask symptoms of PTSD and ASD when assessing for trauma (e.g. Adjustment Disorder and mood or anxiety disorders) (APA,

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2000). Lastly, the clinician must also keep in mind that while PTSD and ASD are indicative of exposure to a traumatic response, they are not the only consequences of trauma. Other effects of trauma may include: self-mutilation, re-victimization, sexual dysfunction, dissociation, alexythymia, and psychosomatic illness (personal communication, 2009). Reactions within both trauma types and diagnostic criteria involve features that comprise what Herman (1992) refers to as the Dialectic of Trauma. She recognizes three trauma responses: hyperarousal (i.e. a continual state of alert), intrusion (i.e. repeated interruption of the traumatic event usually in the form of flashbacks and dreams), and constriction (i.e. a state of helplessness and/or surrender). Herman proposes that the intrusive and constrictive reactions to trauma “establish an oscillating rhythm” (p. 47). That is, because neither of these responses allows the individual to amalgamate the traumatic event into one piece, the individual is constantly attempting to find a middle ground between these two extremes. For example, a woman, raped by her father, may vacillate back and forth between intrusive flashbacks of the horrifying event in which she feels the fear, rage, and panic to feelings of detachment, inability to emotionally connect with others, and at times a lack of feelings altogether (numbing). This switching back and forth, between a reliving mode and a denial mode, perpetuates the individual’s inability to integrate the trauma, and may thus cause more complex problems to arise.
THEORETICAL EXPLANATIONS

I will now discuss three theoretical perspectives from which trauma/PTSD can be understood: behavioral theory, cognitive theory, and a theory of neurobiology. PTSD will be included in this discussion as many of the reactions to trauma are embodied in the diagnostic criteria of this disorder. However, it is important to remember that trauma is a subjective experience. Individuals may respond to trauma in different ways, all of which may or may not interfere with functioning. For purposes of this paper, it will be assumed that the examples provided to highlight theoretical underpinnings are of clinical significance and are traumatic in nature.

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BEHAVORIAL THEORY: CLASSICAL AND OPERANT CONDITIONING Behavioral theory is comprised of two types of conditioning, both of which can be used to explain the development of trauma/PTSD. Classical conditioning stems from the work of Ivan Pavlov and involves particular behaviors that emerge as a response to a particular stimulus (Zastrow & Kirst-Ashman, 2007). A neutral stimulus (NS) is paired with an unconditioned stimulus (UCS) which elicits an unconditioned response (UCR). Unconditioned stimuli produce respondent behavior; this behavior is unlearned and naturally occurs in response to the UCS (Zastrow & Kirst-Ashman, 2007). Even after the UCS is removed, the individual associates the NS with the UCS and develops a conditioned response (CR). This NS then becomes a conditioned stimulus (CS) which now elicits a CR. This can be more easily understood within the context of a traumatic event. For example, consider a woman (Mary) who was raped in a public restroom. During the rape Mary experienced intense fear and felt as though her rapist might kill her. To this day, Mary cannot return to that bathroom without experiencing those same reactions she felt in response to the unexpected attack. The rape was the UCS that produced a natural response of fear and horror (UCR). This was paired with the public restroom which served as the NS. However, following the trauma, Mary has now learned to pair the restroom (the CS) with the same feelings she experienced from her trauma (CR). Additionally, Mary fears not only that specific public restroom in which she was violated, but all public restrooms. This phenomenon, known in behavioral theory, is called generalization (Robbins, Chatterjee, & Canda 2006). Mary has linked the CR (intense feelings of fear and death) with the stimuli that are similar to the CS (public restroom). This example illustrates the ways in which an individual exposed to a traumatic event can associate the event with multiple areas of life, thus impairing the individual’s ability to function normally. One can see how some of the features of PTSD, as indicated in the DSM-IV-TR (APA, 2000) may be explained through this type of learning. Intense psychological distress or physiological reactivity (CR) may generalize and arise when exposed to a reminder or

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symbolized object of the traumatic event (CS); as was the case with Mary and all public restrooms. Individuals may also avoid places, people, or activities that remind them of the traumatic experience due to the intolerable CR. Still, others may experience a startle response (CR) in reaction to a noise (CS) that they associate with the trauma (e.g. a soldier hears a helicopter (CS) which elicits the startle response (CR) due to threat of death by enemy helicopters). However, there is another type of learning that can assist in understanding the trauma response. Operant conditioning is a type of learning in which behaviors are reinforced (Robbins et al., 2006). This type of learning can best be used to explain the avoidance symptom of clusters within PTSD. There are two types of reinforcement: positive, which increases the frequency of behavior through positive consequences experienced immediately following the action, and negative, which increases the frequency of behavior by removing aversive stimuli (Zastrow & Kirst-Ashman, 2007). Negative reinforcement can primarily be used in examining the effects of trauma. Negative reinforcement can be used by examining the vignette of Mary, discussed above. Avoidance of public restrooms serves to negatively reinforce Mary’s fearful memories and physiological reactions to the trauma. By steering clear of public restrooms, reactions to the trauma reminder subside or are avoided completely, and thus increase Mary’s association of the restroom with her trauma response as well as Mary’s likelihood of avoidant behaviors in the future. Through both Classical and Operant Conditioning techniques, many of the symptoms that arise in the trauma response can be explained. However, this theory is less useful when attempting to explain emotional trauma responses other than fear, the deficits in trauma memory recall, and the nature of intrusive re-experiencing (Brewin & Holmes, 2003). COGNITIVE THEORY Cognitive theory allows for a different perception of the effects of trauma/PTSD. Cognitive theories include models that address the ways in which individuals think and understand (Zastrow & Kirst-Ashman, 2007). Within this theoretical framework, it is not

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the traumatic event itself that elicits symptoms of trauma/PTSD, but the appraisal of the event (Brewin & Holmes, 2003). One of the consequences of the negative appraisals, which many traumatized individuals generate post-trauma, is the shattering of belief systems (Janoff-Bulman, 1992 as cited in Brewin & Holmes, 2003). In a study done on victims of assault, Dunmore, Clark, & Ehlers (1999) describe ten cognitive factors they found to be associated with PTSD symptoms. These factors centered on negatively appraised views of the self, the world, and others (Dunmore et al., 1999). Globally, negatively-held beliefs include thoughts such as “There is no goodness in the world,” or, “The world is unjust.” Trauma likewise affected individuals’ views of others, creating thoughts such as “No one can be trusted,” or, “There is no safe place.” Lastly, negative appraisals of the self incite beliefs such as “I am disgusting,” or, “No one will ever love me again.” Dunmore et al. (1999) additionally discuss the role of what Ehlers et al. (1998) refer to as “mental defeat.” This concept refers to an individual having completely given up in his/her mind, and thereby feels defeated, convinced that he/she can no longer protect him/herself (Ehlers et al., 1998). This is a phenomenon often seen in trauma victims and speaks to some of the avoidance symptoms seen in PTSD. Mental defeat may cause an individual not only to feel hopeless and helpless, but to feel that they can no longer trust themselves, let alone others or the world. This may in turn cause these individuals to avoid people, places, or activities that will trigger trauma reminders and put them in a place in which they “know” they will be unable to protect themselves (Dunmore et al., 1999). Additionally, Dunmore et al. discuss the ways in which individuals interpret their symptoms of PTSD, and how this can reinforce the persistence of the trauma reaction. Ehlers & Clark (2000) propose a cognitive theory that specifically addresses the persistence of PTSD symptoms. While this theory does not explain the ways in which cognition influences an individual’s response to trauma, it is useful in understanding how

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symptoms of trauma continue to plague traumatized individuals. Ehlers & Clark speak to the paradoxical nature of PTSD as an anxiety disorder, in that individuals suffering from PTSD are anxious about threats to the self in the future, despite the trauma being rooted in the past (Ehlers & Clark, 2000; Brewin & Holmes, 2003). Thus, Ehlers & Clark suggest that individuals are unable to see the trauma event as time-limited and process the traumatic event as though there is a current threat to the self and that this threat will persist into the future. Ehlers & Clark (2000) state that individuals suffering from PTSD will negatively appraise the traumatic event, leading the individual to believe that the threat is not one of the past, but one of the present and future. Threats can be both internal (to the self) and external (of the world). There are various types of appraisals: appraisals of the traumatic event, appraises of the consequences of the trauma (i.e. initial PTSD symptoms, others’ reactions to the trauma, and various other life consequences of the trauma), and appraisals of the individual’s emotional response to the trauma. In conjunction with the evidence provided above, the cognitions of traumatized individuals are often comprised of negative appraisals that are made toward the self, the world, and the future (Ehlers & Clark, 2000). In this model, negative appraisals of the symptoms of PTSD perpetuate the perceived and impending threat. For example, an adolescent boy has been sexually abused by his older brother. One symptom of PTSD he may experience is psychic numbing, in which he detaches emotionally from others. Ehlers & Clark posit that this boy may then negatively appraise this symptom to the self stating, “I’ll never be able to love anyone,” or while negatively appraising to others, “No one will be able to love me.” This negative appraisal creates the perception that the threat is one of the present and future, not of the past where the trauma actually lies. Ehlers & Clark (2000) have created a list of negative appraisals that reinforce the persistence of PTSD symptoms. Cognitive theory is useful in understanding the helplessness, hopelessness, and mental defeat that individuals exposed to trauma may experience. However, it seems to be more

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useful in explaining the persistence of the trauma response rather than the etiology of the disorder itself. While the theory does illustrate the effects of trauma/PTSD, this theory may be more useful in conjunction with other theories, therefore utilizing a more eclectic theoretical framework. NEUROBIOLOGY The last theoretical lens that will be used to explain the trauma/PTSD is through a neurobiological framework. The role trauma plays in the brain and body is intricate and complex. Therefore, amongst the varying neurobiological systems, a brief description of the normal stress response will be provided followed by a discussion of the differences seen in individuals who have suffered trauma/PTSD. The amygdala may have one of the most critical roles in the stress response as it can be seen as a gateway where sensory input is initially screened. As part of the brain’s limbic system, the amygdala’s primary responsibility is to appraise safety and be attuned to danger (Cozolino, 2002).The amygdala has two paths through which sensory input can be simultaneously received (Cozolino, 2002). In the first, a more primal response, sensory information is taken in through the thalamus and is passed straight to the amygdala. This is the quickest path to activating the fight or flight response. The information is then passed from the amygdala to the hippocampus and then to the prefrontal cortex (Cozolino, 2002; Cohen, Perel, DeBellis, Friedman, & Putnam, 2002). However, as humans have evolved, the brain has developed another pathway. While slower on route to its final destination (the amygdala), this pathway allows individuals to first interpret the sensory stimuli and cognitively process whether it is dangerous or not. This path takes in information from the thalamus, directs it to the prefrontal-cortex (which is in the left hemisphere of the brain), then to the hippocampus (which is responsible for integration of conscious forms of memory), and finally to the amygdala (Cozolino, 2002).

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This process is, however, quite different in an individual who is experiencing trauma. During a traumatic event, the individual is inputting this sensory information through the thalamus and simultaneously sending the information down its circuits. However, during a trauma, it seems as if the hippocampus, where the memory would be stored, shuts down and the memory is stored in sub-cortical regions of the brain which are accessible by the amygdala (Applegate & Shapiro, 2005). The amygdala appears to overreact to the sensory input, which may possibly be the source of the intrusive symptoms of PTSD, as well as the extreme fear that is seen in trauma survivors. This understanding of the way information is processed during a trauma is extremely useful in understanding how traumatic memories are stored and consequently many of the symptoms of trauma/PTSD survivors. The hippocampus primarily stores what is referred to as explicit memory (Cozolino, 2002). Explicit memory is a form of conscious memory from which semantic, sensory, and motor forms of memory are learned and can be pulled into consciousness. This form of memory is what helps us contextualize our experiences and remember them in a certain time and place. Implicit memory, which is stored in the subcortical regions of our brain and is implicated with the amygdala, is memory that involves unconscious learning (i.e. emotional responses, patterns of behavior, automatic skills) (Cozolino, 2002). What becomes problematic for the traumatized individual is the ways in which these memories, or lack thereof, are stored. Implicit memories are stored in the right hemisphere of the brain, which is online at birth, dominant for the first three years of life, and is sensitized to facial expressions. The left brain stores explicit memories, but does not come online until around age four (Cozolino, 2002). This is useful in understanding the ways in which early childhood traumas may be consciously “forgotten.” For example, a child sexually abused at the age of two may not have any explicit memory recall of the event, as the left hemisphere is not online at this age. However, the right hemisphere is online and is

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where implicit memories from this childhood abuse (i.e. fear, anger, immobility) are stored. Even with older children, adolescents, and adults (whose left hemispheres are online), accessing explicit memories may still be difficult due to the hippocampus’ inability to effectively process information during a trauma. The implicit memories, however, will still be there. This explains the inability to recall certain aspects of a trauma among individuals diagnosed with PTSD. It can further help explain symptoms of re-experiencing, and in particular flashbacks, re-enactment, and intrusive thoughts, images, or perceptions. Because the hippocampus was unable to appropriately store the memory of the trauma, traumatized individuals often have no context in which to place the trauma (Cozolino, 2002). Thus, they experience the trauma in the present, often in the form of flashbacks, intrusive thoughts, or re-enactment. These memories of the trauma are often fragmented (due to the poor processing of the hippocampus) and are mostly comprised of implicit memories (i.e. an angry face, the feeling of being slapped, the fear accompanied by lack of control). Even if fragmented memories are able to be retrieved, traumatized individuals often will have difficulty verbalizing the trauma. This is due not only to the more primitive information processing track that is utilized during a trauma (from the thalamus to the amygdala), but also possibly to a decrease in blood flow to Broca’s Area, an area of the left cortex where verbal expression is controlled. This may result in what is referred to as
speechless terror, and will likewise impact the brain’s ability to explicitly store verbal

conscious memory of the trauma as the trauma is processed through the alternative sensory input circuit (Cozolino, 2002). Another neurobiological system to examine is that of the neurotransmitter responsible for attention and focus—norepinephrine (NE) (Cohen et al., 2002). One of the most important roles of NE is its involvement with the fight-or-flight response. When an individual encounters a stressful situation, a surge of NE is released. The locus ceruleus

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(LC), the primary production area of NE, responds to the stressor by increasing levels of NE which are sent to the amygdala. Thus, the NE serves to heighten the functioning of the amygdala, thereby reinforcing the encoding of implicit memory. With traumatized individuals, this mechanism is particularly salient when considering the consequences of intensified implicit memories and fragmented, or lack of, clear explicit memories (Cozolino, 2002; Cohen et al., 2002). This may speak to the exaggerated re-experiencing symptoms of the trauma response. A different neurobiological system that plays a role in the stress response is that of the Hypothalamic-Pituitary-Adrenal (HPA) axis. As a part of the sympathetic nervous system’s normal stress response, the amygdala activates the paraventricular nucleus in the hypothalamus (Cohen et al., 2002). Corticotropin-release hormone is expelled and received by the pituitary gland, which then releases corticotropin (ACTH). ACTH is then collected by the adrenal cortex which releases cortisol into the body (Cohen et al., 2002). As cortisol increases, various other organs in the HPA axis adjust accordingly, and the individual can return to a homeostatic state. However, in an individual who has been traumatized, the individual’s body remains on high alert, and cortisol levels remain high. High levels of cortisol can, in turn, be toxic to the hippocampus, resulting in decreased hippocampal volume (Cohen et al., 2002; Bremner, Randall, Scott, & Bronen, 1995). This may be especially true and should be kept in mind when working with traumatized children (Cohen et al., 2002). Continued stimulation of the HPA axis by the amygdala and the sustained response of the sympathetic nervous system to a trauma will keep the individual in a heightened state of alert (Cohen et al., 2002; Cozolino, 2002). Exaggerated startle response, irritability, and other symptoms within the hyperarousal cluster of PTSD may be a result of this dysregulation (Cozolino, 2002). Additionally, excessive amounts of dopamine in the medial prefrontal cortex may likewise account for some of the trauma symptoms of hyperarousal such as hypervigilance or paranoia (Cohen et al., 2002).

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Lastly, Cohen et al. (2002) also discuss two other reactions to the stress response that differ in individuals suffering from trauma/PTSD. While the role of Serotonin is unclear, it appears that low levels have been found to be associated with consequences of trauma such as suicidality, depression, and aggression. On the other hand, high levels of endorphins, which are released as a part of the normal stress response, may contribute to the psychic numbing and avoidance symptoms experienced by survivors of trauma. However, this connection remains unclear (Cohen et al., 2002).
CULTURAL DIVERSITY CONSIDERATIONS

An exhaustive discussion of cultural and diversity factors implicated in PTSD/trauma survivors is beyond the scope of this paper; however, issues to keep in mind when working with these individuals will briefly be presented here. While trauma is a universal phenomenon, the ways in which a culture classifies, perceives, interprets, and responds to threatening events may differ (Chemtob, 1996). It is important to keep in mind that trauma is ultimately a subjective experience, and different individuals may appraise the distressing experience according to their cultural context (Young, 1994). In a study done by Santos et al. (2008), it was found that non-white traumaticinjury survivors (i.e. American-Indian, African-American, and Hispanic) were more likely to show higher rates of early posttraumatic stress symptoms than white traumatic-injury survivors. Ruef, Litz, and Schlenger (2000) examined possible cultural factors to influence higher rates of combat-related PTSD in Vietnam War veterans. It was hypothesized that possible differences in emotional processing (i.e. difficulty expressing traumatic experience) and coping skills for traumatic events (particularly in combat-related scenarios) may assist in explaining elevated rates of PTSD in the Hispanic population. Additionally, Ruef et al. (2000) postulate that possible intergenerational transmission of learned helplessness due to a sociocultural norm of fatalistic coping mechanisms may be seen in a Hispanic population, as well as in other ethnic minority groups who share similar cultural coping styles. While this is just

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one example of how culture may influence the trauma response, this emphasizes the importance of cultural competence among crisis responders. In a world where cultures are increasingly coming into contact with one another, where integration of multiple cultures is becoming a norm, it is important to understand differences in response to trauma as well as to acknowledge the stress that may accompany these cultural melting pots and thus an individual’s ability to cope with the impact a trauma may present (Chemtob, 1996). In addition to cultural competency, understanding factors that may put certain ethnic/racial/cultural groups at risk is essential. Ford (2008) discusses the ways in which identification or classification with a particular cultural/racial group may put an individual at risk for trauma/PTSD. He highlights the ways in which racism toward a particular group may increase the likelihood of this group’s exposure to trauma and development of PTSD. Further, Ford argues not only how racism acts as a stressor that may predispose certain groups to trauma exposure, but how racism itself may be a psychological trauma. While it appears that more research needs to be done in this area before stronger conclusions can be made between trauma and culture, it is clear that there is a relationship between the two. Cultural competence and understanding of greater macro-level forces that may be at work within particular groups, therefore, is critical in dealing with survivors of trauma/PTSD. One of the most important steps to achieving this awareness is for clinicians treating crisis situations to be familiar with their own cultural identity and how it may impact treatment (Young, 1994). It is with hope that by taking culture into consideration that effective treatments for this vulnerable population will flourish.
TREATMENT

There are several evidence-based interventions that address trauma; however, not all treatments are utilized with both adults and children. Two evidenced-based approaches

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that are used to treat trauma are Prolonged Exposure Therapy for Posttraumatic Stress Disorder (PE), which is designed for use with adults (National Registry for EvidenceBased Programs and Practices (NREPP, 2007), and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), designed for use with children/adolescents (NREPP, 2008). For purposes of this paper, only TF-CBT will be discussed here in that it most closely aligns with the theoretical perspectives presented. TF-CBT is a child-focused evidence-based practice that utilizes cognitive behavioral theories of practice and addresses neurobiological complications that are seen in survivors of trauma. This intervention is designed to treat trauma/PTSD as well as emotional and behavioral problems that often arise in children who have experienced a trauma (NREPP, 2008). One of the core components of this practice is its adaptable use among varying cultures, as the authors of the treatment recognize the influence culture has on the trauma response. Treatment components can be summarized through the acronym PRACTICE (Cohen et al., 2006; Cohen & Mannarino, 2008). Psychoeducation is used to assist the parent and the child/adolescent in understanding the impact of trauma and the symptoms the child/adolescent may be experiencing. Additionally TF-CBT utilizes a Parenting Component, in which parents of the traumatized child/adolescent receive paralleled sessions to assist in developing parenting skills and to allow the parent(s) to process the trauma of their child. As has been discussed previously, negative appraisals surrounding symptoms of trauma can exacerbate/reinforce the persistence of PTSD (Ehlers & Clark, 2000). Thus, both these components may serve to ease anxiety and reframe negative appraisals. Relaxation Skills are taught to addresses many of the physiological symptoms that accompany trauma/PTSD (i.e. hyperarousal). Parents are additionally taught skills to aid in their own self-care. Cohen et al. (2002) suggest relaxation techniques be used to assist

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children/adolescents in coping with many of the effects of heightened norepinephrine levels (i.e. flashbacks, hyperarousal). Affect Expression and Modulation Skills sequentially follows presenting skills that assist children in their ability to effectively express and modulate their emotions. Cohen et al. (2002) discuss a lack of connection between the right and left hemispheres in traumatized individuals. This may result in an inability to link feelings with verbalizations or manifest as a restricted range of affect, as is seen in survivors of trauma. Cognitive Coping and Processing (Part I) is the portion of treatment that assists children in recognizing the connection between thoughts, emotions and behaviors; combining tenants from both cognitive and behavioral theory. Once this is done, the child can begin the Trauma Narrative (Cohen et al., 2006). Applegate & Shapiro (2005) emphasize, from a neurobiological perspective, the importance narratives serve in connecting neural networks from implicit memory with explicit memory. By repeatedly discussing the traumatic event, the idea is that the child will become more comfortable thinking about the event, thus gradually reducing or diminishing symptoms of PTSD brought about by this lack of neural connection (Cohen et al., 2006; Applegate & Shapiro, 2005). The second part of the Trauma narrative is Cognitive Coping and Processing (Part II) in which the therapist begins to discuss with the child the feelings and emotions surrounding the traumatic experience, identifying cognitive distortions and assisting the client in reframing these negative appraisals. In Vivo Mastery is the next component that works further with the child to master traumatic memories and cope with the symptoms they may be experiencing. This takes a behavioral approach, and is particularly useful in dealing with trauma/PTSD symptoms of avoidance. Co-Joint Sessions are the next step in allowing the child to integrate the trauma further through sharing the narrative with his/her parent(s). Lastly, Enhancing Future Safety and Development assists the child/adolescent in any specific skills still needed by the child and/or family members (i.e. for a child who has been sexually

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abused, this treatment component may include creating a safety plan) (Cohen et al., 2006). This brief description delineates the techniques used to treat trauma through a behavioral, cognitive, and neurobiological lens.
CONCLUSION

The impact of trauma is complex and multifaceted. This paper has presented a brief description of trauma and the trauma response, as well as three theoretical lenses through which trauma and PTSD can be explained. While these theoretical frameworks are useful, they are, alone, unable to account completely for all the manifestations of the trauma response. Using an eclectic approach when working with survivors of trauma may be most effective. Additionally, cultural competence among clinicians is essential in understanding the greater forces that may be at hand when working with traumatized individuals. Lastly, choosing a treatment modality that will specifically address the needs of this population is vital to successful recovery. It is through theory, however, that one can first begin to understand the manifestations of trauma as well as the foundation upon which treatment is guided.

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REFERENCES American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th Ed., text revision). Washington DC: American Psychiatric Association.

Applegate, J. & Shapiro, J. (2005). Neurobiology for clinical social work: Theory and practice. New York: W.W. Norton and Co. Basham, K. (2008). Trauma theories. In J. Berzoff, L.M. Flanagan, & P. Hertz (Eds.), Inside out and
outside In (2nd Ed.) (p. 411-441). Northvale, NJ: Jason Aronson.

Bremner, J.D., Randall, P., Scott, T., & Bronen, R.A. (1995). MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder. American
Journal of Psychiatry, 152, 973-981.

Breslau, J. (2004). Cultures of trauma: Anthropological views of posttraumatic stress disorder in international health. Culture, Medicine, and Psychiatry, 28, 113-126. Brewin, C.R. & Holmes, E.A. (2003). Psychological theories of posttraumatic stress disorder. Clinical
Psychology Review, 23, 339-376.

Chemtob, C.M. (1996). Posttramatic stress disorder, trauma, and culture. International Review
Psychiatry, 2, 257-277.

Cohen, J.A. & Mannarino, A.P. (2008). Trauma-focused cognitive behavioural therapy for children and parents. Child and Adolescent Mental Health, 13(4), 158-162. Cohen, J.A., Mannarino, A.P. & Deblinger, E. (2006). Treating trauma and traumatic grief in
children and adolescents. New York, NY: The Guilford Press.

Cohen, J.A., Perel, J.M., DeBellis, M.D., Friedman, M.J., & Putnam, F.W. (2002). Treating traumatized children: Clinical implications of the psychobiology of posttraumatic stress disorder.
Trauma, Violence, and Abuse, 3(2), 91-108.

Cozolino, L. (2002). The neuroscience of psychotherapy. New York: W.W. Norton. Dunmore, E., Clark, D.M., & Ehlers, A. (1999). Cognitive factors involved in the onset and maintenance of posttraumatic stress disorder (PTSD) after physical or sexual assault.
Behaviour Research and Therapy, 37, 809-829.

Ehlers, A. & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour
Research and Therapy, 38, 319-345.

Ehlers, A., Clark, D.M., Dunmore, E., Jaycox, L., Meadows, E., & Foa, E.B. (1998). Predicting response to exposure treatment for PTSD: the role of mental defeat and alienation.
Journal of Traumatic Stress, 11, 457-471.

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Ford, J.D. (2008). Trauma, posttraumatic stress disorder, and ethnoracial minorities: Toward diversity and cultural competence in principles and practices. Clinical Psychology: Science and
Practice, 15(1), 62-67.

Herman, J. (1992). Trauma and recovery. New York, NY: Basic Books. National Registry of Evidence-based Programs and Practice (2007). Prolonged exposure therapy
for posttraumatic stress disorders. Retrieved December 5, 2009, from

www.nrepp.samhsa.gov/programfulldetails.asp?PROGRAM_ID=200. National Registry of Evidence-based Programs and Practice (2008). Trauma-focused cognitive
behavioral therapy. Retrieved September 28, 2009, from

www.nrepp.samhsa.gov/programfulldetails.asp?PROGRAM_ID=217. Robbins, S., Chatterjee, P., & Canada, E. (2006). Contemporary human behavior theory: A
critical perspective for social work (2nd Ed.) Boston: Allyn and Bacon.

Ruef, A.M., Litz, B.T., & Schlenger, W.E. (2000). Hispanic ethnicity and risk for combat-related posttraumatic stress disorder. Cultural Diversity and Ethnic Minority Psychology,
6(3), 235-251.

Santos, M.R., Russo, J., Aisenberg, G., Uchara, E., Ghesquiere, A., & Zatzick, D.F. (2008). Ethnic/ racial diversity and posttraumatic distress in the acute care medical setting. Psychiatry,
71(3), 234-245.

Terr, L. (1991). Childhood traumas: an outline and overview. American Journal of Psychiatry,
148(1), 10-20.

Young, M.A. (1994). Cultural perspectives on trauma. In The community crisis response team
training manual (2nd Ed.), (Ch. 8) [Online]. Retrieved October 22, 2009, from

www.ojp.usdoj.gov/ovc/publications/infores/crt/. Zastrow, C.H. & Kirst-Ashman, K.K. (2007). Understanding human behavior and the social
environment (7th Ed.). Belmont, CA: Thomson Learning, Inc.

Review of Three Approaches to Play Therapy: Child-Centered Play Therapy, Filial Therapy, and Sandplay Therapy
DEBORAH BAUMAN
Directed Research in Social Work Professor Eugenia Weiss

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INTRODUCTION TO PLAY THERAPY

Play is the universal language of children and the principal activity of childhood (Landreth, 2002). The value of play for healthy cognitive development, language development, social competence and physical development is widely recognized (Reddy, Files-Hall & Schaefer, 2005). Piaget posited that play helps connect concrete experience and abstract thinking; it is therefore the symbolic aspect of play that is critical to a child’s development (Schaefer, 1993). Through play, children can master feelings, thoughts and experiences through symbolic representation that may be difficult to manage or directly express in reality (Landreth, 2002). Because children are not developmentally equipped to adequately express themselves verbally, a therapist can use play with children experiencing psychosocial problems or serious mental disorders because it is their natural means of self-expression (Landreth, 2002). In the presence of an empathic adult or therapist, children will express their feelings and needs through play materials of their choosing (Schaefer, 1993). “Play therapy” is a general term that refers to a range of therapeutic interventions that vary greatly regarding elements, such as use of direction by the therapist, interpretation and involvement with members of the family (Johnson, Bruhn, Winek, Krepps, & Wiley, 1999). The common aspects of these approaches are the view of play as the child’s medium of communication and the use of play materials in treatment. For clarification, The Association for Play Therapy (2001) defined play therapy as “the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development” (p. 20). Uses of play therapy are broad: it can be used to aid in diagnosis of a child, build a therapeutic relationship, reduce maladaptive defenses, assist children to verbalize difficult feelings, facilitate the expression of unconscious material and relieve associated tension, and discover interests that can be transferred to daily life (Gil, 2002). Play therapy has a variety of curative powers, including increasing the child’s potential for self-expression and communication,

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problem-solving, discharge or abreaction of emotion, working through difficult or painful life experiences, and enhancing relationships (Schaefer, 1993). A wide range of theories serve as a foundation for play therapy; these theories shape different approaches to play therapy, and the field at large. Leading schools of play therapy are client-centered, cognitive-behavioral, family, and psychodynamic; each places different emphases on the curative powers of play (Reddy, Files-Hall, & Schaefer, 2005). There is also a prescriptive school of play therapy that promotes the view that play therapists should apply play therapy approaches differentially to fit the needs of clients (Reddy et al., 2005). Although there is a paucity of research supporting the efficacy of one model over another (James, 1997), a meta-analysis by Ray, Bratton, Rhine and Jones (2001) on the efficacy of play therapy concluded that this intervention was effective across theoretical schools of thought. For the purposes of the present paper, this writer will explore three theoretical approaches to play therapy: Child-Centered Play Therapy, Filial Therapy, and Sandplay Therapy. APPLICATIONS Play therapy can be used to treat a broad range of presenting problems (Gil, 2002). Play therapy has been shown to have positive treatment outcomes with children across all diagnostic categories, except “the completely autistic and the out-of-contact schizophrenic” (Landreth, 2002, p. 45). Examples of children’s presenting problems for which there is empirical support for the intervention of play therapy include: hair pulling, selective mutism, conduct disorder, aggressive and oppositional behavior, ADHD, adjustment problems for children of divorce, abuse and neglect, sexual abuse, child witnesses of domestic violence, separation anxiety, depression, psychosomatic difficulties, maladaptive school behavior, bereavement, adjustment problems related to chronic illness, developmental delays, reading difficulties, speech and language problems, posttraumatic stress disorder, and adjustment related to multicultural difference (Ray et al., 2001; Landreth, 2002). Play therapy is a flexible intervention; the

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most comprehensive meta-analysis to date by Ray et al. (2001) found that play therapy appears effective across modality (individual and group), age, gender, and settings. Play therapy is appropriate with children between the ages of three and ten, but can also be useful with preadolescents and early adolescents, especially if play materials are developmentally appropriate (James, 1997). RESEARCH ON THE EFFICACY OF PLAY THERAPY There is a strong need to prove the usefulness of play therapy if it is to be accepted widely. In the current climate of managed care, play therapists are pressured to provide empirical support for the effectiveness of this intervention (Reddy et al., 2005). Practitioners are asked by the legal system, third-party payors, school administrators and parents who have to approve their child’s form of therapy to provide evidence of the effectiveness of play therapy (Ray et al., 2001). Despite the strong theoretical underpinning of play therapy, some critics have challenged its efficacy, charging that the field lacks sound scientific research (Reddy et al., 2005; Ray et al., 2001). The criticism has been based on the paucity of rigorous research designs and methods in studies to evaluate its clinical utility (Reddy et al., 2005). The research that does exist lacks control groups and has been primarily based on narrative case studies with limited or no generalizability, and process and outcome research (Bratton & Ray, 2000; Carroll, 2000). However, more recently, well-designed controlled experimental studies have been undertaken. Two meta-analytic studies have evaluated play therapy for its effectiveness with children (LeBlanc & Ritchie, 1999; Ray et al., 2001). Taken together, the two meta-analyses reveal that play therapy treatments have moderate-to-large positive effects (.66 to .80) as measured at outcome. Interestingly, both studies showed increased positive effects with the added factors of parental involvement in therapy and duration of sessions (Ray et al., 2001). In spite of the strength of these meta-analyses in answering the charges of critics and providing evidence for its effectiveness, the authors note that most play therapy research

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continues to use small sample sizes, and thus have limited generalizability (Ray et al., 2001). Some researchers recommend that because play-based techniques are geared towards emotions and symbolic expression, which are generally incompatible with scientific methods, future study designs should incorporate both processes and outcomes (Campbell, 2004; Carroll, 2000). However, Reddy et al. (2005) recommend further rigorous experimental studies assessing outcomes of play interventions, and present guidelines for future outcome evaluation that include behavior scales, direct observation, and the use of assessment instruments during play.
CHILD-CENTERED PLAY THERAPY

Child-centered play therapy (CCPT) follows the theoretical model of client-centered therapy developed by Carl Rogers (Landreth & Sweeney, 1997). Virginia Axline adapted Carl Rogers’ theory of personality structure and philosophy to working with children (Gil, 2002). CCPT is based on three central constructs: the person, the phenomenal field, and the self, with a focus on self-concept (Landreth & Sweeney, 1997). To elaborate, child-centered play therapists place their focus on the whole child rather than on the presenting problem. It is not always even necessary for the therapist to know about the background of the child’s maladjustment. The phenomenal field is the child’s internal frame of reference; the therapist must appreciate the child’s perception of reality if his behaviors are to be understood (Landreth & Sweeney, 1997). Maladjustment is viewed as resulting from a discrepancy between the child’s outer experience and his inner selfconcept (Landreth, 2002). Additionally, child-centered play therapists help children access their natural striving towards growth and development through their unconditional acceptance of who the child is (Axline, 1974). This attitude of permissiveness helps a child attain self-actualization, become less defensive, and develop confidence and selfdirection (Gil, 2002). Axline set forth eight basic principles of CCPT in which the therapist has a warm, caring relationship with the child; accepts the child for who he is; creates a sense of

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permissiveness in the relationship that frees the child; recognizes and reflects the child’s feelings; maintains respect for the child; follows the child’s lead in play and conversation; does not hurry the process of therapy; and sets appropriate limits for the child (Axline, 1974). The last principle is critical because CCPT does not endorse a completely permissive relationship; limits provide safety for the child, physically and psychologically, and anchor the session to reality (Axline, 1974). To promote the child’s full selfexpression in a safe environment, Axline recommended that the therapist select toys and materials that promote a wide range of feelings and activities (Axline, 1974; Landreth & Sweeney, 1997). APPLICATIONS CCPT is mostly used with children under age ten; however, positive results have been demonstrated with ten- to fourteen-year-old children, with play materials adapted for developmental appropriateness. CCPT is especially well suited for children from different socioeconomic classes and ethnic backgrounds, since the child can freely communicate through play; indeed, play materials can be culturally adapted to the child (Landreth & Sweeney, 1997). CCPT has been used to treat a wide spectrum of childhood problems (Johnson et al., 1999), including separation anxiety and speech disturbance in preschool children, adjustment problems of children of alcoholics, and mental retardation (Johnson et al., 1999). Based on this writer’s research, other examples of presenting problems for which CCPT has been applied include the self-esteem, locus of control and anxiety level of at-risk children (Post, 1999); sexually abused children (Scott, Starling, Burlingame, Porter, & Lilly (2003); low self-confidence of African American boys at the elementary school level (Baggerly & Parker, 2005); and child witnesses of domestic violence (Kot, Landreth, & Giordano, 1998). To elaborate on the application of CCPT to treat children who have witnessed domestic violence, Kot et al. (1998) describe the use of intensive play therapy with a child-centered approach to treat children who have been exposed to domestic violence. Research

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has shown that children who witness domestic violence experience more internalizing and externalizing behavior problems, increased academic problems, and interpersonal conflicts (Kot et al., 1998). CCPT is a useful intervention for these traumatized children to prevent maladjustment by affording them a safe environment with a supportive therapist to disclose what they have witnessed (Kot et al., 1998). Through the child-centered techniques, children engage in a self-curative process to replay stressful events that have rendered them helpless, thus increasing their sense of control and assisting them to learn coping skills (Kot et al., 1998; Schaefer, 1993). The authors used intensive sessions due to the relatively short duration a child might stay at a domestic violence shelter. Results of the authors’ study demonstrated the effectiveness of CCPT with this population. Children in the experimental group showed statistically significant improvement in their self-concept, reduction in externalizing and total behavior problems, and an increase in play behaviors of physical proximity and positive play themes, as assessed using valid and reliable measures (Kot et al., 1998). RESEARCH ON THE EFFICACY OF CHILD-CENTERED PLAY THERAPY A literature search using search terms that included “child-centered play therapy,” “evidence,” and “efficacy” with different databases (Google Scholar, PsycArticles, ProQuest) yielded limited results, with the exception of the two most recent and comprehensive meta-analyses by Ray et al. (2001), and LeBlanc and Ritchie (1999). Reflecting the state of research on play therapy, most of the articles the search produced used case studies only, although some more recent studies were conducted with experimental designs. Although these controlled studies offer empirical support for the use of child-centered therapy, they are geared for particular populations and problems only and generally have small sample sizes. It is therefore necessary to turn to the metaanalyses to form sound conclusions. The meta-analysis by LeBlanc & Ritchie (1999) of 42 experimental studies evaluated characteristics or predictors of treatment that correlated to outcome success, but

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did not analyze different theoretical approaches as predictors of treatment outcome. Therefore, although the authors (1999) found that play therapy is an effective treatment modality for children, it is not possible to reach conclusions about the particular efficacy of CCPT from their meta-analysis. The meta-analysis by Ray et al. (2001) coded 74 out of 94 studies as using a humanistic/non-directive theoretical model, 12 as behavioral/ directive, and included eight that could not be coded. The humanistic/non-directive category demonstrated a larger effect size (.93) than the behavioral/directive category (.73), producing a statistically significant difference. Although the authors (2001) do not regard this difference as significant due to the low number of studies in the behavioral category, the large effect range for the humanistic/non-directive category certainly provides strong empirical support for the use of non-directive CCPT to treat a broad range of presenting problems. Although a more detailed analysis of the precise nature of the approaches in the humanistic/non-directive category is beyond the scope of the present discussion, the meta-analysis overall provides strong empirical support for the use of child-centered techniques.
FILIAL THERAPY

Filial therapy (FT) was developed by Bernard and Louise Guerney in the 1960s as a way to reduce children’s psychosocial problems, improve parenting skills, strengthen parent-child and family relationships, and address family conflicts (VanFleet, Ryan & Smith, 2005). FT can be considered a hybrid form of CCPT in that parents or other main caregivers are trained by a therapist to conduct non-directive play sessions with their own children (Johnson et al., 1999). Parents therefore become the primary agents of change for their children (Guerney, 2001). A rationale for FT is the fact that as the parent-child relationship is almost always the most important in a child’s life, the child’s experience of self-expression and acceptance in the parent-child matrix should in theory produce a stronger effect than with a therapist (Guerney, 2000).

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To train parents, filial therapists use psychoeducation to impart skills and attitudes that can help resolve the child’s problems and improve family relationships. The model supports the view that parents have the resources to bring about change, a message that offers hope and deflects the focus away from pathology and possible etiology (VanFleet et al., 2005). Parents receive training through a combination of didactic instruction, watching videotapes, role-playing, and supervision (Tew, Landreth, Joiner & Solt, 2002). After the practice sessions, parents begin to carry out sessions with their children. Parents are taught to relate more positively to their children, correcting cycles in which parent and child misunderstand the others’ feelings or behaviors (Guerney, 2000). This approach strengthens the parent-child bond, which in turn fosters the child’s healthy development (VanFleet et al., 2005). As stated by Guerney (2000), another goal of FT it to help strengthen family relationships; FT helps families achieve the characteristics of close families (as cited in Sinnette and De Frain, 1985). Because FT blends play therapy with family therapy, it is important that the therapist has training in each approach. Although the child-centered play sessions are eventually conducted by the parents, the therapist must oversee the process to bring about successful treatment for both the child and parents, and be sensitive to the family’s needs (VanFleet et al., 2005). APPLICATIONS OF FILIAL THERAPY The strength of filial therapy as a preventive and clinical intervention has been evidenced with a wide range of child or family problems, including oppositional defiant disorder, attention deficit disorder, chronic medical illness, child or family trauma, adolescent parents, single parents, domestic violence, attachment disruptions, family reunification, kinship and foster care, and adoption (VanFleet et al., 2005). Furthermore, VanFleet et al. (2005) state that filial therapy has been adapted to a variety of settings, including clinical practice and schools, and with multicultural populations (as cited in VanFleet & Guerney, 2003). Guerney (2001) points out that FT is not intended to be applied for children with organic

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problems such as autism, but only for behavioral or emotional problems. Furthermore, FT is not considered effective with parents with serious mental disorders, who would not have the capacity to train and conduct play sessions (Guerney, 2001). Specifically, filial therapy has been used as an intervention for parents and families of chronically ill children. As stated by Tew et al. (2002), there is substantial evidence that chronic illnesses can lead to psychological maladjustment in children as these ongoing conditions place great psychosocial stress on both children and parents (as cited in VanFleet, 1992). Filial therapy is well-suited to the needs of this population as this treatment helps strengthen parent-child bonds and increases family cohesiveness, thus increasing coping ability of all members (Tew et al., 2002). Chronically ill children use the treatment to communicate fears and feelings associated with their illness through play, thus reducing emotional and behavioral problems. Parents learn to increase acceptance of their children and to reduce their level of stress. The effectiveness of this intervention for parents and families of chronically ill children was demonstrated in the controlled study conducted by Tew et al. (2002) that showed greater parental acceptance of the child, decreased parental stress, and reduced child problem behaviors in the group receiving filial therapy; however, the authors note the need for follow-up studies. RESEARCH ON THE EFFICACY OF FILIAL THERAPY In the meta-analysis conducted by Ray et al. (2001), out of 94 studies reviewed, 28 focused on the effectiveness of filial therapy. The evaluation revealed that filial therapy was an effective intervention for children’s difficulties, with large effect sizes compared to nontreatment groups that performed at 1.06 standard deviations above nontreatment groups (Ray et al., 2001). In fact, the authors (2001) state that the parental involvement utilized in filial therapy “significantly increased the effectiveness of play therapy” (p. 94). Consistent with the findings of the meta-analysis, a critical review of the empirical support of filial therapy over the past 45 years revealed consistent positive outcomes to treat a wide range of presenting problems (VanFleet et al., 2005). Numerous controlled

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studies have shown filial therapy’s efficacy in alleviating children’s presenting and behavioral problems, increasing parental acceptance and skills, and lowering parents’ level of stress (VanFleet, 2006). Furthermore, follow-up studies have demonstrated that therapeutic gains are sustained three and five years post-treatment (VanFleet, 2006).
SANDPLAY THERAPY

Sandplay is an expressive arts play therapy technique that blends a client-centered approach with a Jungian focus on archetypal and symbolic meanings (Hunter, 2006). Of the expressive arts techniques, sandplay has been described as especially engaging for children, who enjoy making images in the sand or miniature worlds with small objects (Zinni, 1997). Although sandplay is sometimes placed under the rubric of a psychodynamic theoretical approach in that sandplay affords access to the child’s unconscious (Zinni, 1997), it is often subsumed under Jungian play therapy (Zinni, 1997). It is, however, of note that Zinni (1997) stresses that sandplay has become widely accepted in clinical practice, and is not currently viewed as “an esoteric Jungian tool” (p. 658). Dora Kalff, a student of Carl Jung’s, further developed Margaret Lowenfeld’s technique from the 1920s in which children created “worlds” in sandtrays, and devised the current version of sandplay therapy (Hunter, 2006). Kalff refocused the method to incorporate Jung’s belief that the psyche holds the collective unconscious, and developed Jung’s active imagination technique into a concrete use of sandplay (De Domenico, 1994). She encouraged therapists to have a knowledge of symbols and myths to interpret the child’s expression in the “free and sheltered space” (Kalff, 1980, p. 32). In sandtray work, children use a tray that is filled halfway with wet or dry sand, water, and optionally with a collection of miniature and natural objects to create a scene or design in the confines of a larger container that is termed “temenos” (De Domenico, 1994). Kalff recommended having numerous toy figures available to the child to bring out the inner expression of self. Through sandplay work, the child can activate the healing power of symbols (De Demenico, 1994).

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To elaborate on the Jungian perspective, Jungian play therapists believe the individual psyche has the capacity to heal itself in a safe and protected environment in the context of a supportive transference relationship (De Domenico, 1994; James, 1997). The content of play, reflecting the client’s inner world, reveals impulses toward growth of the personality. The scenes and designs in the sand reveal the unconscious conflicts of the child; sandplay promotes healing and integration by reorganizing contents of the unconscious that have been expressed symbolically (Green, 2009). The Jungian sandplay therapist must be familiar with archetypes, cultural and religious traditions. She strives to recognize these aspects of the collective unconscious manifested in the child’s play that can teach “the meaning-making matrices of their ancestors” (De Domenico, 1994). The Jungian sandplay therapist also needs to be attentive to motifs and themes in the child’s sand tray that express cycles of creation and destruction inherent in the life cycle (Hunter, 2006). As in client-centered non-directive play therapy, the therapist must refrain from judgment, interference, or giving directions (Hunter, 1994). APPLICATIONS Sandplay can be flexibly adapted to different settings and used to treat a wide range of presenting problems and disorders, including adjustment disorders, learning and communication deficits, anxiety, depression, bereavement and loss, trauma and abuse, posttraumatic stress, developmental delays, mood disorders, and borderline and psychotic states (Hunter, 2006; Carey, 2006). It can be used effectively for culturally diverse children, as this metaphorical form crosses barriers; miniature figures used from the child’s culture can promote a sense of belonging (Hunter, 2006). Sandplay can also be used as a long- or short-term model, and can succeed as a treatment with individuals or groups. A specific application of sandplay that has been described by authors Green and Connolly (2009) in a case study is Jungian family sandplay (JFS) with bereaved children. The rationale for treatment is that children under the age of ten who experience loss may

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experience psychosocial problems as they may not be developmentally able to process grief as well as an older adolescent or adult (Green, 2009). Although the authors (2009) note the paucity of empirical support for play therapy with bereaved children, case studies provide anecdotal support at least that sand therapy may help reduce symptoms associated with grief such as irritability, social withdrawal, insomnia, and guilt (as cited in Carey, 1991). Through sandplay, children can express loss, say goodbye to loved ones, and reintegrate the loss while remaining anchored (Green, 2009). Because the child experiences loss in the context of family, Green and Connolly (2009) suggest including family members in treatment following several individual play sessions with the child to better meet the needs of the bereaved child (Green & Connolly, 2009). Using a familysystems lens, the authors (2009) share a case study of a six-year-old boy whose father had suddenly died from a drug overdose who undergoes JFS with his mother. Through JFS, the mother became more emotionally available to the son, and the sandplay enabled the boy to symbolically express grief in a way that was developmentally appropriate. The authors (2009) emphasize that they are not recommending JFS as a treatment of choice for grieving children, but rather as a powerful tool and option in treatment planning. RESEARCH ON THE EFFICACY OF SANDPLAY THERAPY A literature search on the evidence for the effectiveness of sandplay therapy that employed different terms and databases (Google Scholar, PsychArticles, ProQuest) yielded little-to-no results. The scarcity of empirical support for this modality was noted by Campbell (2004), who confirms, “few studies have attempted to provide scientific validation for this technique” (p. 7). Demonstrating this point, in the meta-analysis conducted by Ray et al. (2001), only one study out of 94 utilized sandplay as an intervention (Ney, Palveskey, and Markely, 1971), meeting criteria for a rigorous research design that warranted inclusion in the evaluation. Furthermore, this sandplay study had a sample size of only 20 participants, limiting its generalizability. However, countering the bias towards evidence-based interventions, Campbell (2004) asserts that the many case studies that show positive outcomes of sandplay therapy should nevertheless be

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considered “valid clinical evidence” (p. 8). The author (2004) suggests that the lack of scientific validation for sandplay therapy may instead reflect limits in methodology, rather than treatment ineffectiveness.
CONCLUSION

The three play therapy techniques discussed in this paper are all respected and much utilized methods of carrying out therapy with a child. Although the three forms of play therapy share some key underlying principles, they differ in the manner in which therapy is conducted, the role of the therapist, the use of play materials (although they are the same in child-centered and filial therapy), and the emphases of treatment. CCPT emphasizes that the child’s use of toys is his form of communication and release, and that interpretation is not necessary to resolve difficulties (Schaefer & O’Connor, 1983). FT is a hybrid of CCPT and family therapy in that parents are the primary providers of childcentered play therapy for their own children; this modality further places a greater focus on the family system than CCPT (Guerney, 2003). The emphasis in FT is more on directly strengthening the bond between parents and children than in CCPT, although gains in the parent-child relationship can be made using CCPT with an individual child. In FT, the therapist must play a more supervisory role, in addition to that of therapist, compared to CCPT. In contrast to the humanistic schools of thought of child-centered and FT grounded in Rogers’ client-centered therapy, Jungian sandplay is a more psychodynamic approach in that there is a greater focus on the revelation of unconscious content through the world the child creates in the sand (Green, 2009). However, CCPT, FT, and Jungian sandplay therapy share Rogers’ philosophy that the child has an innate capacity for growth and self-healing (Hunter, 2006). Jungian sandplay additionally emphasizes the transpersonal healing power of symbols as revealed through sandplay. All three techniques share basic principles of play therapy, namely that the child is not a miniature adult (Landreth, 2002), that the best way to connect with a child is through play and the use of play media, that play serves a function for the child of

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communication and self-expression, and that the child uses play to work through and resolve problems (Schaefer & O’Connor, 1983). Furthermore, all three approaches place a central value on the importance of the child’s relationship with an empathetic therapist whose sensitive understanding and acceptance fosters the child’s process of self-realization (Axline, 1974; Landreth, 2002; Hunter, 2006). Encapsulating the child’s response to the healing experience of play therapy, Axline (1974) quotes a child in play therapy, who says of the therapist’s work, “I mean I wouldn’t know how to do what she does. I don’t even know what she does. She doesn’t seem to do anything. Only all of a sudden, I’m free. Inside me, I’m free” (p. 19). This child’s words stand as a testimony to the power of play therapy.

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REFERENCES Association for Play Therapy. (2001, June). Play therapy. Association for Play Therapy
Newsletter, 20, 20.

Axline, V. (1974). Play therapy. New York: Random House Publishing Group. Baggerly, J. & Parker, M. (2005). Child-centered group play therapy with African American boys at the elementary school level. Journal of Counseling & Development, 83(4), 387-396. Bratton, S., and Ray, D. (2000). What the research shows about play therapy. International
Journal of Play Therapy, 9(1), 47-88.

Campbell, M. (2004). Value of sandplay as a therapeutic tool for school guidance counsellors.
Australian Journal of Guidance and Counseling, 14(2), 211-232.

Carey, L. (2006). Short-term family sandplay therapy. In H.G. Kaduson & C.W. Schaefer (Eds.),
Short-term play therapy for children, 2nd Ed. (pp. 202-216). New York, N.Y.:

The Guilford Press. Carroll,J. (2000). Evaluation of therapeutic play: A challenge for research. Child & Family
Social Work, 5(1), 11-22.

De Domenico, G. (1994). Jungian play therapy techniques. In K.J. O’Connor & C.W. Schaefer (Eds.), Handbook of play therapy, volume two: Advances and innovations (pp. 253-282). New York: John Wiley & Sons, Inc. Gil, E. (2002). Play therapy with abused children. In F.W. Kaslow, R.F. Massey and S.D. Massey (Eds.) Comprehensive handbook of psychotherapy, volume 3: Interpersonal,
humanistic, existential (pp. 59-82). New York: John Wiley & Sons, Inc.

Green, E., and Connolly, M.E. (2009). Jungian family sandplay with bereaved children: Implications for play therapists. International Journal of Play Therapy, 18(2), 84-98. Guerney, L., (2000a). Filial therapy into the 21st century. International Journal of Play Therapy,
9(2), 1-17.

Guerney, L. (2001b). Filial play therapy. In C.E. Schaefer (Ed.) Foundations of play therapy (pp. 99-142). Hoboken, N.J.: John Wiley & Sons, Inc. Hunter, L. (2006). Group sandtray play therapy. In H.G. Kaduson & C.W. Schaefer (Eds.),
Short-term play therapy for children, 2nd Ed. (pp. 273-304). New York, N.Y.:

The Guilford Press.

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James, O. (1997). Play therapy: A comprehensive guide. Northvale, N.J.: Jason Aronson, Inc. Johnson, L., Bruhn, R., Winek, J., Krepps, J. & Wiley, K. (1999). The use of child-centered play therapy and filial therapy with head start families: A brief report. Journal of
Marital and Family Therapy, 25(2), 169-176.

Kalff, D.M. (1980). Sandplay: A psychotherapeutic approach to the psyche. Santa Monica, CA: Sigo Press. Kot, S., Landreth, G., & Giordano, M. (1998). Intensive child-centered play therapy with child witnesses of domestic violence. International Journal of Play Therapy, 7(2), 17-36. Landreth, G.L. (2002). Play therapy: The art of the relationship. New York, N.Y.: BrunnerRoutledge. Landreth, G.L. & Sweeney, D.S. (1997). Child-centered play therapy. In K. O’Connor & L.M. Braverman (Eds.), Play therapy theory and practice: A comparative presentation (pp. 17-45). New York: John Wiley & Sons, Inc. LeBlanc, M. & Ritchie, M. (1999). Predictors of play therapy outcomes. International Journal
of Play Therapy, 8(2), 19-34.

Ney, P., Palvesky, A. & Markely, J. (1971). Relative effectiveness of operant conditioning and play therapy in childhood schizophrenia. Journal of Autism and Childhood
Schizophrenia, 1, 337-349.

Post, P. (1998). Impact of child-centered play therapy on the self-esteem, locus of control, and anxiety of at-risk 4th, 5th, and 6th grade students. International Journal of Play
Therapy, 8(2), 1-18.

Ray, D., Bratton, S., Rhine, T., & Jones, L. (2001). The effectiveness of play therapy: Responding to the critics. International Journal of Play Therapy, 10(1), 85-108. Reddy, L.A., Files-Hall, T.M., & Schaefer, C.E. (Eds.) (2005). Empirically-based play
interventions for children. Washington, D.C.: American Psychological Association

Schaefer, C. (Ed.) (1993). The therapeutic powers of play. Lanham, MD: Rowman & Littlefield Publishers, Inc. Schaefer, C. & O’Connor, K. (Eds). (1983). Handbook of play therapy: Volume one. New York: John Wiley & Sons, Inc.

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Scott, T., Burlingame, G., Starling, M., Porter, C. & Lilly, J.P. (2003). Effects of individual client-centered play therapy on sexually abused children’s mood, self-concept, and social competence. International Journal of Play Therapy, 12(1), 7-30. VanFleet, R. (2006). Short-term play therapy for adoptive families: Facilitating adjustment and attachment with filial therapy. In H.G. Kaduson & C.W. Schaefer (Eds.), Short-term
play therapy for children, 2nd Ed., 145-168. New York: The Guilford Press.

VanFleet, R., Ryan, S.D., & Smith, S.K. (2005). Filial therapy: A critical review. In L.A. Reddy, T.M. Files-Hall, and C.E. Schaefer (Eds.) Empirically based play interventions
for children (pp. 241-264). Washington, D.C.: American Psychological Association.

Zinni, V.R. (1997). Differential aspects of sandplay with 10- and 11-year-old children. Child
Abuse & Neglect, 21(7), 657-668.

SECONDARY SOURCES
Carey, L. (1991). Family sandplay therapy. The Arts in Psychotherapy, 18, 231-139. Stinnett, Nick; DeFrain, John (1989). The healthy family: Is it possible? In Fine, Marvin J., (Ed.), The second handbook on parent education: Contemporary perspectives (pp. 53-71). Academic Press, Inc., New York, U.S.A. (1989) VanFleet, R. (1992). Using filial therapy to strengthen families with chronically ill children. In L. Vandecreek, S. Knapp, & T.L. Jackson (Eds.). Innovations in clinical practice:
A source book (pp. 87-97). Sarasota, FL: Professional Resource Press.

VanFleet, R. & Guerney, L. (2003). Casebook of filial therapy. Boiling Springs, PA: Play Therapy Press.

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Evaluation Research Design in the Immigrants’ Rights Project
ERIN DOWLER
Evaluation of Research: Community Organization, Planning and Administration Professor Jacquelyn McCroskey

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INTRODUCTION AND BACKGROUND

Public Counsel was founded by the Beverly Hills Bar Association in 1970. Initially called the Beverly Hills Bar Association Law Foundation, it was the first bar-sponsored public interest law firm in the country. In 1977, the Los Angeles County Bar Association joined the Beverly Hills Bar Association as a sponsor of the Law Foundation. This joint endeavor resulted not only in a name change to Public Counsel, but also in an expansion of the organization’s purposes and goals. Direct involvement in public interest litigation was coupled with a mandate to mobilize and coordinate pro bono efforts of the Los Angeles legal community to serve the poor. The mission is stated as follows: “Founded in 1970, Public Counsel is dedicated to advancing equal justice under law by delivering pro bono legal services to indigent and underrepresented children and adults, ensuring that community-based organizations serving this population have legal support, mobilizing the volunteer resources of the private bar, and providing technical assistance to pro bono attorneys and projects throughout California.” The goals are: “to generate increased involvement of the Los Angeles legal community in pro bono activity, to marshal a variety of volunteer resources from outside the legal community, to undertake direct representation as co-counsel or amicus in selected impact matters, to enhance the delivery of legal services through involvement in public policy discussions and community education, and to improve and secure Public Counsel’s ability to deliver legal services through cultivation of community resources and leaders” (Public Counsel, 2009). “There are 33 attorneys along with over 3,600 volunteer lawyers, law students and legal professionals that assist over 26,000 low-income children, youth, adults and families, as well as eligible community organizations each year” (www.publiccounsel.org). Public Counsel maintains very limited data on client demographics. The available data is broken down into four categories of ethnicity (White, Black, Asian, and Native American), gender, and number of clients served, broken down by fiscal year. The limiting categories are

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confusing and create dilemmas for the purpose of this paper because a majority of clients are Latino, thus rendering the data irrelevant. The clients served at Public Counsel are both male and female, generally between the ages of 1 and 72 years old, are of many different ethnicities, and come from many different countries. Although the clients are of various ethnic backgrounds, those served are often of Mexican and Central American, African, or Southeast Asian descent, and of lower socioeconomic status. Within Public Counsel there are a number of programs: Immigrants’ Rights Project, Homelessness Prevention Project, Early Care and Education Law Project, Consumer Law Project, Community Development Project, Appellate Law Project, and Childrens’ Rights Project (CRP). The program to be evaluated is the Immigrants’ Rights Project (IRP), which provides legal representation to individuals seeking asylum, relief under the Victims of Trafficking and Violence Protection Act of 2000 (VTVPA), Special Immigrant Juvenile Status (SIJS), relief under the Violence Against Women Act (VAWA), and representation in unusual immigration cases involving compelling humanitarian or public policy issues (Public Counsel). IRP frequently works with the Childrens’ Rights Project to assist with special immigrant juvenile status (SIJS) in situations of neglect, abuse, or guardian absence (Public Counsel).
PROBLEM, PROPOSED INTERVENTION, AND LOGIC MODEL

The Southern California area consists of the following counties: Imperial, Los Angeles, Orange, Riverside, San Bernardino, and Ventura. The sociodemographic profile of this region which is served by Public Counsel is a population of 18.5 million as of 2006 (U.S. Census Bureau, as cited by SCAG), consisting of 44% Latino, 39% non-Hispanic White, 12% Asian, and 7% African American (SCAG, 2009). In 2006, it was estimated that approximately 31% of this region’s total population were foreign-born (SCAG). Pew Hispanic Center (2005) estimates that there are close to 1.5 million unauthorized immigrants in this region as of 2004 (Southern California Association of Governments). The goal of IRP, that is relevant to this evaluation as stated by Public Counsel and

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summarized by the attorneys, is the delivery of quality legal services to achieve the best possible outcome for each client. In discussions on how to achieve the best possible legal outcome for each client two additional goals were discovered: first, achieve attorney satisfaction by alleviating the attorneys’ heavy workloads due to case management of clients’ needs outside of the legal realm and second, long term client empowerment. The main objectives to achieve these goals are: support clients through phone calls and in-person meetings, provide referrals, link clients with a community they identify with, advocate for larger policy changes that impact clients, set mutually agreed upon goals, and broker with hard-to-reach systems and educate their key stakeholders about barriers to clients’ access of systems. The variables relevant to Public Counsel and the Immigrants’ Rights Project are the lack of free or low-cost services for low-income individuals, the fact that families are often ineligible for public benefits, and confusion on behalf of public service providers regarding the benefits IRP clients are eligible for. Furthermore, these variables, as an aspect of immigration status in the United States, are also barriers in formulating, testing, and implementing this proposed evaluation model. Location is also an obstacle. In the Southern California region there are high population cities such as San Diego and Los Angeles, where social services are more accessible. Other areas are rural or desert area where social services are limited, but housing is inexpensive for many of the clients served. Although Public Counsel has been in existence for almost 40 years, IRP has been around for about 18 years. The social work model that is used in CRP began about 20 years ago, but the use of this social worker-attorney model would be a new program for IRP. Over the past 20 years, the social work-attorney approach has been modified as needed, but there has never been an official needs assessment or program evaluation committed to the social work-attorney partnership. Because of the nature of the unique approach and

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the lack of data that supports such a relationship, a review of the literature for a lack of timely services and case management within a legal setting turned up virtually little research or data. In order to gain access to recent literature on a social work model in a legal setting, an evidence-based search was conducted on the following databases: Google Scholar, Social Work Abstracts, Social Service Abstracts, ProQuest, PsychINFO, and Academic OneFile. Although articles, dissertations, and books were found when searching using the terms “social work AND legal setting”, “social work AND law”, and “social work AND attorneys”, there appeared to be no research that specifically looks at a social work model of case management in a pro bono legal setting like Public Counsel. In order to justify the need for case management of clients in IRP, a second search was conducted around the bio-psycho-social needs of immigrant populations coping with side effects from physical and psychological torture and abuse, slavery, sexual assault, rape, domestic violence, neglect, or human trafficking. The databases searched were Google Scholar, Social Work Abstracts, Social Service Abstracts, ProQuest, PsychINFO, and Academic OneFile using keywords such as “refugees”, “asylees”, “human trafficking”, “immigrants AND domestic violence”, “immigrants AND social work”, “refugees AND social work”, “trafficking victims AND social work”, “sexual assault AND social work”, and “asylum AND social work” among others. These search terms are by no means conclusive. In reviewing the literature about the experiences of immigrants and the prevalence of traumatic stress (both voluntary and involuntary) in individuals adjusting to life in a new country, it is clear the immigration process is filled with obstacles from learning a new language (Segal & Mayadas, 2005) to falling prey to employers ready to take advantage of those not familiar with the host culture, observed through personal experience. Fyvie et al (2003, as cited in Phillimore & Goodson, 2008) describes that the integration of

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refugees necessitates education and training in health, the labor area, and housing as key areas of focus before integration can begin. Moving to a new country means leaving behind family, friends, possessions, and status in a society, which impacts all immigrants in one way or another (Potocky-Tripodi, 2002). This fact further complicates individuals’ abilities to cope with physical, mental, and emotional health issues, especially as individuals who are at risk for oppression and race-based discrimination (Segal & Mayadas; Potocky-Tripodi). Traumatic experiences also impact immigrants’ ability to adjust to their new life or to access resources. Posttraumatic stress disorder (PTSD) frequently accompanies voluntary immigrants and very often accompanies involuntary immigrants (Potocky-Tripodi). Many survivors of traumatic experiences, such as domestic violence and torture survivors, frequently experience PTSD (Balgopal, 2000; Carlson, McNutt, Choi, & Rose, 2002). Victims of such violence often have low levels of functioning and lack access to resources (Busch & Valentine, 2000). Victims also are believed to have low self-efficacy, which means they do not feel they have the ability to control their situation. In the case of domestic violence, victims most often doubt their ability to start life over in the case of leaving a perpetrator, thus feeling safer staying with the batterer (Busch & Valentine, 2000). Self-efficacy issues relate to a sense of power or lack of it (Potocky-Tripodi; Busch & Valentine), a significant factor among immigrants trying to start a new life. Before delving into interventions and assistance for clients, it is important to establish a rapport. As with any client, this is important in order to distinguish whether any challenges the client faces are emitted from individual issues or if they are effects from organizational or societal problems (Segal & Mayadas). As is the case in IRP, such differentiations are often key to winning cases, as well as providing competent social work services. Immigrants that seek legal services from Public Counsel-IRP frequently struggle with language barriers, employment, and culture shock in addition to PTSD as a result of traumatic violence, life-long instability, or sexual violence.

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The proposal to build a multidisciplinary case management approach for IRP is based on the existing model in use by CRP social workers and attorneys. The proposed program will address the identified problems of the present role attorneys play: the time consuming role of stabilizing and supporting clients in order to build successful cases, providing competent referrals for multiple needs, and advocating on behalf of the client. The proposed case management approach would allow attorneys to focus their time on the legal work, which personal interviews conducted as part of a needs assessment revealed is a major source of stress and strain (K. Werth, personal communication, September 25, 2009). Therefore, the intended audience for the proposed program and evaluation is the attorneys of IRP. The case management would take place within the office building of Public Counsel with clients being referred to a social worker as necessary. The social work approach to case management has proven beneficial to both attorneys and social workers in CRP because the social workers have been able to address client needs so clients are able to function from day to day. For example, once clients begin receiving therapy, they begin consistently showing up for work, and, finally achieving permanent housing, they are able to meet their legal obligations such as coming to scheduled appointments and hearings, helping to build their case (J. London, personal communication, October 2, 2009; K. Jackson, personal communication, date unknown; B. Tsoulos, personal communication, October 9, 2009). The importance of a social worker-attorney program for the agency, funders, and stakeholders is based on the reputation and success of CRP using such a social work case management model for about 20 years. This program is relevant to society, the field of social work, and Public Counsel because the social work role uses interventions that help clients to obtain a level of functioning where they can contribute to society. It is evident in United States immigration policies that society expects individuals to be productive and contribute to society. This is clear in

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the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 where affidavits of support are required for an immigrant’s application for permanent status, providing proof that a sponsor can, and will, financially support the applicant (U.S. Citizenship and Immigration Services). U.S. Citizenship and Immigration Services (USCIS) also require proof of good moral character, proof of a residence, and English language abilities (USCIS) when applying for naturalization. Miriam Potocky-Tripodi summarizes that non-U.S. born individuals have higher unemployment and poverty rates, as well as a lower salary and a lower rate of home ownership (2002), making it challenging for individuals to meet the stringent requirements of USCIS. The program is also relevant to social work. Social work’s approach of viewing strengths and weaknesses in the environment of the individual (M. Ziegler, personal communication, October 2, 2009) is uniquely suited to address obstacles by empowering clients, gaining access to resources and skills, and advocating on behalf of clients. According to NASW Code of Ethics, social work’s commitment to service and social justice (NASW) would serve the needs of the immigration population as discussed above. Based on the needs of IRP’s client population, the clients clearly are underrepresented and indigent with regard to the high rates of poverty, evidenced by the lack of services available to clients to meet these needs, based on professional experience. Based on this knowledge about challenges immigrants face, coupled with traumatic experiences, it is clear that clients in the Immigrants’ Rights Project would benefit from referrals and being linked up with services. Often times, the IRP attorney is the only person in the client’s life who provides assistance, and confusion often ensues about the attorney’s role in providing legal services versus personal support. This places a burden on the attorneys who frequently find they spend more time emotionally supporting their clients. Based on these findings, that clients seeking legal representation frequently need additional support, the social work case management model is the best intervention to start with for this pilot program. A logic model

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displays the proposed outline for IRP, addressing the goals, inputs, activities, outputs, and outcomes, including the measures. The logic model displays a series of six interventions (the independent variables) that are intended to produce five outcomes (the dependent variables). As mentioned earlier in the literature review, no literature was found that supports or rejects a social work case management model in a legal setting. However, the activities of supporting clients through phone calls and in-person meetings, as well as provide referrals that meet client needs can serve to improve social functioning (Hepworth et al, 2006). It is expected that improved social functioning will positively influence the outcomes of improved living conditions and client empowerment. Empowerment can also be encouraged through aspects of the Lum model (1996) including: mutual goal setting, identifying and recognizing strengths, and brokering with systems that are often out of reach for disempowered individuals. The final activity, advocating for policy changes that impact clients is also one of the key purposes of social work, according to the Council on Social Work Education (CSWE, 2002, as cited in Hepworth et al). Policy changes help to decrease the number of obstacles for clients, as do all of the independent variables. Although the long term goal of empowering the client is difficult to measure, Grinnell, Gabor, and Unrau (2010) note that this type of performance data is important because only monitoring the number of clients served, as opposed to the changes that should occur (increased empowerment), workers may no longer focus on the client outcome but on how many clients are served. Therefore, it will be important in this program to continue to monitor ways in which clients are empowered. This example demonstrates the importance of the relationship between the proposed activities and the expected outcomes. All of the interventions are designed to improve attorney satisfaction. RESEARCH QUESTIONS The research questions that will address the program outcomes are: Will supporting the client, providing referrals, mutual goal setting, identifying and recognizing client

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strengths, and brokering with hard to reach systems help to improve client living conditions, decrease the number of obstacles for the client, obtain the best possible legal outcome, and empower the client? Will all of the program activities serve to support the client at a level that attorneys are satisfied with the provision of social work support? Will advocating for policy changes that impact the clients decrease the number of obstacles facing the client?
RESEARCH DESIGN

The proposed evaluation methods are based on the social work case management model outcomes. Because there is little to no existing data on this case management model as previously discussed, an internal monitoring approach combined with the use of an ongoing needs and strengths assessment will help focus on quality improvement (Grinnell, Gabor, & Unrau, 2010) with respect to the attorney workloads and their ability to focus on the legal work. The methods can be integrated into the evaluation, which would help provide immediate feedback (Grinnell, Gabor, & Unrau). Currently, the existing model in CRP requires tracking of clients by the attorneys, but not the social workers. The needs and strengths assessment plan will identify the needs and strengths of IRP, as well as the clients for the first year or two of the program. This will help to determine the best case management services that can be provided to help the clients, thus meeting the attorney needs of timely and reliable case management services to enhance the legal aspect of the case. The proposed data collection methods are subject to change. Recent data identifies the need for more social services with regard to the income generated by U.S. born versus non-U.S. born individuals living in the United States (Fortuny & Passel, 2007). Data is very difficult to obtain for asylees and recipients of various visas and forms of relief that IRP services. Therefore, a great need exists for more data collection on behalf of Public Counsel with regard to how many clients are seen, what services and forms of relief clients receive, and long-term client well being. Data collection on client information

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should not pose much resistance with clients because the collection could coincide with attorney-client appointments; however, there is possibility for internal challenges regarding time constraints. There does not appear to be a system in place that can collect and manage this type of data for the purpose of generating reports. The remaining data to be collected using mixed methods focuses on the outcomes. Ordinal quantitative methods will be used in surveys to measure attorney satisfaction and client report of living conditions. Tracking ongoing attorney satisfaction will occur on a bi-monthly basis, in the form of a non-standardized needs assessment questionnaire (Grinnell, Gabor, & Unrau). In order to monitor the satisfaction of the attorneys and whether or not their needs are being met, regular surveys, followed by semi-regular interviews, and bi-annual focus groups would be excellent ways to find out if the proposed program is meeting the needs of the main audience, the attorneys. Using interviews is beneficial when little is known about the problem area (Grinnell, Gabor, & Unrau). The client living conditions survey will be administered every three months for the first year they are a client. After this, the survey will be administered bi-annually. Key informants to be identified could also play a role in the strengths and needs assessment, as well as during the ongoing collection of data for the evaluation (Grinnell, Gabor, & Unrau). The self-report of the number of obstacles for the client will use qualitative methods in order for the client to indicate through interview what obstacles exist, if any. This will take place at the same time the living conditions survey is administered. Whether or not the best possible legal outcome is achieved will be assessed as necessary through qualitative methods of attorney interview and case review. Case review is currently conducted every week at Public Counsel. The minimum data collection will be conducted bi-annually. Client empowerment will be measured bi-annually using quantitative methods from the Rogers, et al (1997) empowerment scale description. Additional data will need to be tracked to maintain basic client information. There could be cooperation in finding new information technology software to manage this data, as it is important for future funding.

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Data collection instruments for collecting data via technology (i.e., computer) could be a simple task of entering data in Microsoft Excel or a similar database. However, the more sophisticated data base the better because it is important to centralize the data for future program growth. SAMPLING STRATEGY Due to the lack of current data on clients, it is unclear what the sample size will be. It would be unethical to withhold services from clients who express any sort of need for assistance in an area of their life, or if the attorney has concern for a client’s well being. Therefore, all clients will be assisted as necessary. INFORMED CONSENT, ANONYMITY, CONFIDENTIALITY The procedures for obtaining informed consent and confidentiality will occur when the client agrees to accept legal services from Public Counsel. An additional intake form will explain the range of case management services provided and that the data collected will track progress, as defined in the outcomes of this program. The program is unable to maintain anonymity due to the nature of the setting in Public Counsel and the legal and social work services provided. ANALYSIS PLAN The plan for data analysis is to create new data because there is little available data from Public Counsel. While the attorneys are the main audience for the program evaluation, it is important to collect data on clients in the form of quantitative data, in order to measure such things as the number of families living at or below the poverty line, who is receiving services, and client presence at required appointments. The dependent variables are attorney satisfaction, living conditions of the client, legal outcome achieved, number of obstacles for client, and client empowerment. The independent variables are support clients through phone calls and in-person meetings,

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provide referrals, link clients with a community they identify with, advocate for larger policy changes that impact clients, set mutually agreed upon goals, and broker with hard to reach systems and educate their key stakeholders about barriers to clients’ access of systems. In assessing the tool to measure empowerment, a test and retest will eventually be conducted after the pilot program to ensure stability of the empowerment instrument. The test and retest will use 10% of the sample at baseline once a baseline has been established through the pilot. A possible sample survey for satisfaction will be the basis for measuring the satisfaction of attorneys regarding the social work services provided (Larsen et al, 1979), as well as client satisfaction with their living conditions. Change will be measured through an increase or decrease in attorney satisfaction, increase or decrease in the living conditions of the client, increase or decrease in the number of obstacles facing the client, whether or not the best possible legal outcome is achieved or being achieved, and an increase or decrease in client empowerment. A oneway MANOVA is the presumed method of data analysis for the quantitative measures because the program is looking for improvement in more than two dependent variables. The qualitative measures should have an underlying theme of client independence and improved quality of life. The attorneys should also show an improvement in overall satisfaction of social work case management services being provided. Finally, disseminating and communicating the information from the evaluation will occur in a presentation during a meeting to discuss the findings. The presentation will focus on graphs to display the collected data and other relevant information, which will help to present the evaluation process in a clear manner. The presentation must also remain on point and fairly brief to accommodate busy work schedules. Based on the gathering of information to create the problem identification and needs assessment, it is clear that the program evaluation will be modified as it is used.

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Although the dilemma of not already having a case management model in place is clear, the data to support having such a model is not currently available due to the nontraditional social work setting. Ongoing data collection is necessary while the program is implemented and the evaluation is conducted.
RELEVANCE TO MACRO PRACTICE

This social work case management model is relevant to a number of areas. The model is relevant to Public Counsel, the community, and other practitioners working in multidisciplinary settings. First, the model has tremendous relevance to Public Counsel because only one project currently has full time social workers who provide case management services. The proposed evaluation model would not only provide consistent services to another department, but the data collected could provide much needed evidence to gain more funding for IRP, as well as justification for replicating this model in other projects within Public Counsel or other law centers. For example, the Homelessness Prevention Project also has clients that are in need of support that the attorneys cannot provide. The data collected could potentially help Public Counsel to strategically influence policy at state and federal levels. The model is also relevant to the community because the case management provides services and referrals that address root causes of poverty (Huston & Bentley, 2010). Mediators of poverty are the same factors that immigrants deal with when arriving to a new country and throughout their lifetime: education, children, housing, family, and material resources (Huston & Bentley). Finally, this model is relevant to macro practitioners because the program addresses the interrelationship between micro and macro practice (Netting, Kettner, & McMurty, 2008). Other macro practitioners that work in interdisciplinary settings will find that there is a great opportunity to reach out to clients that come to an organization for one type of service. These services could be other law centers, medical clinics, or community centers.

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This model compliments the idea of beneficence that Jansson (2008, as cited in Netting, Kettner, & McMurtry) illustrates in an example of an attorney who works on divorce cases but does not consider how this financially impacts the divorcee. Macro practitioners should consider the multiple needs of individuals and communities (Netting, Kettner, & McMurtry), which this proposed model addresses.
FEEDBACK ON PROPOSED EVALUATION

Feedback is a key piece of program evaluation (Grinnell, Gabor, & Unrau, 2010). It has been a challenge to obtain inter-agency feedback for this proposal. The goal is to present this proposal for feedback in the spring semester of 2010 to the attorneys in IRP. Time constraints have made it difficult to obtain such feedback. When conducting a needs assessment earlier in the semester, the main focus for the social work internship was to provide case management for the clients as outlined by the attorneys based on need. The goal was to design this proposal and present it once the attorneys became familiar with the role of a social work intern. However, feedback during the needs assessment conducted in late September and early October revealed that case management services provided by a social work intern provided immediate attorney gratification and relief. The relief was in the form of reducing client phone calls to the attorney and reducing attorney concern for not having the capacity to assist the client outside the legal service realm. This information was key feedback in developing the program activities and outcomes, as well as the evaluation. In addition, feedback from Beth Tsoulos, the field instructor at Public Counsel, has been critical. She has been able to testify how her role as a social worker has influenced the legal process for the attorneys, as well as revealed other issues that might impact the client’s quality of life and the progression of the case. Feedback from the supervisor supported the key components of this program development and evaluation through first-hand experience.

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AGENCY EXPERIENCES WITH THE EVALUATION PROPOSAL

Meetings with agency employees consisted of consultation with the field supervisor and all of the attorneys in IRP. Meetings with the field supervisor, Beth Tsoulos, took place during weekly supervision. The role of a social worker in an interdisciplinary setting was discussed, as well as how to address differences in opinion between social workers and attorneys. Beth has overwhelmingly supported the evaluation because it would not only benefit IRP, but also CRP, which currently does not collect data or track clients. These meetings have made it clear that the program and evaluation would fulfill a tremendous need for additional support and data for Public Counsel. Meetings with the attorneys have provided evidence that the attorneys feel overwhelmed by client needs. It has also been emotionally draining for some attorneys who struggle to avert clients’ needs for follow up services in order to focus on time-sensitive tasks related to the legal case. In some meetings, attorneys clearly express their knowledge about what their clients needs are. This point is particularly important because although the attorneys know their clients very well and the obstacles they face, they do not have the time to conduct a bio-psycho-social assessment to ensure that the full picture is taken into account. I truly believe this model program has the potential to effectively meet the needs of the agency and community. As an intern, I currently provide many of the case management services that the clients and attorneys need. This experience has been a major part of the rationalization for the program outline and evaluation proposal. Most certainly approaches to the model will be modified once the program is put in place and has received initial survey feedback from the attorneys and the clients.

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REFERENCES Balgopal, L. R. (2000). Social work practice with immigrants and refugees: An overview. In L. R. Balgopal (ed) Social work practice with immigrants and refugees (pp. 1-29). New York: Columbia University Press. Busch, N. & Valentine, D. (2000). Empowerment practice: A focus on battered women.
Affilia, 15(1), 82-95.

Carlson, B. E., McNutt, L., Choi, D. Y., & Rose, I. M. (2002). Intimate partner abuse and mental health: The role of social support and other protective factors. Violence Against
Women, 8(6), 720-745.

Electronic reference formats recommended by the American Psychological Association. Retrieved October 13, 2009, from www.publiccounsel.org. Fortuny, K., & Passel, J., (2007). The characteristics of unauthorized immigrants in California, Los Angeles County, and the United States, the Urban Institute. Retrieved October 13, 2009, from www.scag.ca.gov/sotr. Golding, J.M. (1999). Intimate partner violence as a risk factor for mental disorders: A meta analysis. Journal of Family Violence, 14(2), 99-123. Grinnell, R.M. Jr., Gabor, P.A., Unrau, Y.A. (2010). Program evaluation for social workers:
Foundations of evidence-based programs (5th ed.). New York: Oxford

University Press. Huston, A. & Bentley, A. (2010). Human development in societal context. Annual Review of
Psychology, 61, 411-437.

Kasturirangan, A. (2008). Empowerment and programs designed to address domestic violence.
Violence Against Women, 14(12) 1465-1475.

Khamphakdy-Brown, S., Jones, L., Nilsson, J., Russell, E., and Klevens, C. (2006). The empowerment program: An application of an outreach program for refugee and immigrant women. Journal of Mental Health Counseling, 28(28), 38-47. Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/ patient satisfaction: Development of a general scale. Evaluation and Program
Planning, 2, 197-207.

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Lum, D. (1996). Social work practice and people of color (3rd ed.). Pacific Grove, CA: Thomson Brooks/Cole. National Association of Social Workers. (approved 1996, revised 2008). Code of ethics of the
National Association of Social Workers. Retrieved on October 13, 2009, from

www.socialworkers.org/pubs/code/code.asp Netting, E.F., Kettner, P.M., & McMurtry, S.L. (2008). Social work macro practice. Boston: Pearson Allyn and Bacon. Phillimore, J. & Godson, L. (2008). Making a place in the global city: The relevance of indicators of integration. Journal of Refugee Studies, 21(3), 305-325. Pitocky-Tripodi, M. (2002). Best practices for social work with refugees and immigrants. New York: Columbia University Press. Public Counsel. (2009). General information packet. Segal, U. & Mayadas, N. (2005). Assessment of issues facing immigrant and refugee families.
Child Welfare, 84(5), 563-583.

Southern California Association of Governments. (2007). The state of the region reports. Retrieved on October 13, 2009 from www.scag.ca.gov/sotr/ United States Citizenship and Immigration Services (2009). Legislative history from 1981-1996. Retrieved on October 14, 2009 from www.uscis.gov/files/nativedocuments/ Legislation%20from%201981-1996.pdf.

Conceptualizing Pedophilia through Theory, Neurobiology, and Culture
JENNIFER GEBAUER
Human Development and Mental Health Professor Doni Whitsett

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Pedophilia is a complex mental health issue that has been significantly ignored within the mental health community. Pedophilia may be defined as an adult sexually assaulting a prepubescent child (i.e. any form of genital contact or attempt to elicit sexual excitement from a child) (Rice, Harris, Lang & Chaplin, 2008). Currently, society’s preference for managing pedophiles is permanent incarceration. As this is not a viable or ethical option, significant time and attention has been spent developing interventions aimed at reducing relapse and recidivism; however, the etiological cause of pedophilia has not been fully understood, creating the appearance that pedophilia is untreatable (Rice, Harris, Lang, & Chaplin, 2008). A question must be posed. How will pedophilia be effectively treated if the origin of the behavior is unknown? This paper attempts to provide a biopsychosocial perspective on an individual with pedophilia through the lenses of Attachment Theory and Self-Psychology. These theories were chosen to explain pedophilia as they address the preoccupied and fearful attachment patterns that fuel sexual deviancy in child molesters (Wood & Riggs, 2009). Also, they explain the underlying shame exhibited by a significant population of pedophiles (Sawle & Colwell, 2001). Neurological factors will also be explored, and a discussion of diversity issues will be provided, as the focus of this paper is on the adult male pedophile. Finally, a treatment plan will be proposed aimed at addressing the theoretical and neurobiological underpinnings of pedophilia.
ATTACHMENT THEORY

According to Bowlby (1969), the capacity of an infant to develop a close relationship with a primary caregiver occurs because of the attachment system (1969). The purpose of this system is to regulate behaviors (i.e. smiling, cooing) that will assist the infant in maintaining closeness to a primary caregiver for protection (Ward, Hudson, & Marshall, 1996). The dyadic relationship that occurs between the child and the primary caregiver typically lays the foundation for future relationships and impacts the way in which a

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child is able to experience intimacy as an adult. If a disruption in the attachment process occurs, it can result in insecure attachment, a lack of self-confidence and identity, and the inability to develop intimate relationships. Attachment Theory, originally developed by John Bowlby, assists in understanding the complex issue of pedophilia as it explains the intimacy and empathy deficits exhibited by sex offenders. This theory also provides a foundation for understanding the affect misattunement displayed by pedophiles (McCormack, Hudson, & Ward, 2002; Ward, Hudson & Marshall, 1996). In order to understand how Attachment Theory conceptualizes pedophilia, the following topics will be addressed: internal working models of attachment, a safe haven and a secure base, attachment styles, adult attachment, and the misattunement of the pedophile.
INTERNAL WORKING MODELS OF ATTACHMENT

A primary concept in attachment theory is that the infant is an initiator in developing a relationship with the primary caregiver. An infant is not born a “tabula rasa”, but rather, he is equipped with “behavioral systems” that assist in attaining the attachment goals (Bowlby, 1969). Behaviors including babbling, smiling, crawling, and walking are all attempts to obtain positive reciprocal interactions from the attachment figure. If these behaviors are reciprocated, they lead to a sense of security. However, if these positive feelings are not returned the negative emotional states such as anxiety, anger, or sorrow develop. Through these positive and negative interactions with the primary caregiver, the infant develops feelings about himself, others and the world, also known as an internal working model of attachment. In the case of pedophilia, if the parent rejects the infant’s attempts for comfort or exploration, the child may develop an internal working model of being unworthy or incompetent (Bretherton, 1992). While such negative interactions do not cause pedophilia, they lay the groundwork for the development of persistent low self-

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esteem, feelings of worthlessness and insecurity, which are three factors closely associated with pedophilia (Ward, Hudson, & Marshall, 1996; Kear-Colwell & Boer, 2000; Sawle & Colwell, 2001). The early infant and childhood internal working models typically persist throughout life because individuals typically enter relationships that confirm the negative beliefs and cognitive distortions about the self and others (Wood & Riggs, 2009). Consequently, this creates a life-long pattern for the potential pedophile as his persistent low self-esteem and feelings of worthlessness are continuously confirmed through relationships. Furthermore, the disappointment of experiencing negative interactions results in a failure to develop the social skills and self-assurance necessary to achieve intimacy with adults (Ward, Hudson, & Marshall, 1996).
A SAFE HAVEN AND SECURE BASE

Two essential components in the application of Attachment Theory to pedophilia are the concepts of developing a secure base and having a safe haven. A secure base is essentially finding a sense of security with a primary caregiver so the infant or child can explore the world and then return for safekeeping. The concept of a secure base continues throughout life and is utilized during stressful experiences (e.g. a stressed social work graduate student will seek comfort from her husband). Similarly, a safe haven is also created through the dyadic relationship of the primary caregiver and infant. The comfort and security provided to the infant from the primary caregiver soothes the infant’s emotions and the infant is eventually able to develop self-soothing capabilities (Bowlby, 1969). It is through the development of the secure base and safe haven from which affect regulation begins. Consequently, if a child does not have a safe haven or a secure base from which to explore, the individual will have difficulty coping with stressful and anxious situations in adulthood. In the case of a pedophile, it is theorized that intimacy and security needs are displaced onto children as he does not possess the self-soothing

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skills required to maintain affect regulation. Nor does he possess the confidence or social skills required to seek safety through an appropriate secure base, such as an adult romantic partner. This displacement likely occurs when stressful relationship situations arise for the potential pedophile, such as rejection or separation (Sawle & Colwell, 2001).
ATTACHMENT STYLES

Internal working models, a safe haven, and a secure base have a direct impact on the development of an attachment style and the ability to create healthy adult relationships. According to Mary Ainsworth, there are three primary forms of attachment for infants: secure, anxious/ambivalent, and avoidant (Bowlby, 1969). The latter two forms of attachment are also known as insecure attachment patterns, which are associated with pedophilia (Ward, Hudson, & Marshall, 1996). Secure attachment is the ideal attachment style as it is formed when a parent responds lovingly and affectionately to his or her child. Adults who are securely attached feel valued by others, which creates resiliency (Sawle & Colwell, 2001). However, an individual who develops insecure attachment patterns likely did not have his emotional needs consistently met or he experienced continuous rejection. According to Ward, Hudson and Marshall (1996), insecure attachment is linked to the onset of intimacy deficits and developing pedophilic behaviors. Anxious/ambivalent attachment is a form of insecure attachment, and it develops when the caregiver does not consistently respond to the infant. This can result in attention-seeking behaviors, impulsiveness, and a sense of helplessness (McCormack, Hudson, & Ward, 2002). Anxious /ambivalent attachment is most commonly associated with pedophilia (Bartholomew, 1990). Avoidant attachment is developed when the caregiver is unresponsive to the child. Avoidant attachment, which results in a lack of empathy and antisocial behavior, is typically associated with rapists.

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Clearly, the early interactions experienced by the infant, such as a stressed mother who cannot consistently meet the emotional and security needs of an infant, creates a vulnerability in insecurely attached children. The vulnerability may then be exacerbated by environmental stressors, such as physical abuse, neglect or sexual abuse, further worsening a child’s ability to develop a healthy level of self-esteem and affect regulation. According to Wood and Riggs (2009), many offenders who develop insecure attachment patterns had abusive or neglectful childhoods. In fact, 43% of male pedophiles reported they had experienced sexual relations with an adult prior to age 14 (Sawle & Colwell, 2001). While abuse is not required for the development of pedophilia, it must be considered as one predisposing factor to insecure attachment and the progression of pedophilic behaviors.
ADULT ATTACHMENTS

The attachment styles of children and adults are essentially the same with regards to maintaining a secure base and having a safe haven, which is typically attained by a child from his caregiver and by an adult from his romantic partner. However, the primary difference between childhood attachment and adult attachment is the sexual mating system (Woods & Riggs, 2009). Consequently, insecurely attached adults, also known as fearful, preoccupied, or dismissive, do not know how to meet their relational desires or engage intimately with others. Due to the misconstrued internal working models of attachment, the potential pedophile seeks intimacy and security needs through sex. The search to fulfill his needs becomes dangerous when the individual does not want to be rejected and he seeks sexual relationships with children. This is known as fearful attachment. The search to meet such needs becomes similarly dangerous when the potential pedophile is skeptical of the value of close relationships and becomes hostile. This attachment form is known as dismissive. Finally, the search to meet such needs becomes dangerous when the potential pedophile becomes preoccupied with sex. This attachment schema is known as preoccupation

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(Bartholomew, 1990). Individuals who possess these forms of attachment patterns have intimacy desires, but do not have the interpersonal skills, the emotional-wellbeing or the empathy required to develop a romantic relationship with a peer (Sawle & Colwell, 2001). In lieu of seeking adults to meet emotional needs, the insecurely attached pedophile seeks children to avoid true “emotional involvement” (Bartholomew, 1990). While there are three forms of pedophilic behaviors, the primary attachment pattern exhibited by child molesters is preoccupied (anxious-ambivalent). According to Lyn & Burton (2004), pedophiles are more frequently anxious-ambivalently attached as the onset of pedophilic behavior occurs as a result of a hyper-activation of the attachment system (rejection, grief and loss, relationship-issues). As a result, the potential pedophile feels significant anxiety during a stressful situation and does not possess an appropriate secure base. Consequently, out of the anxiety that is created, they seek to fulfill their needs and decrease their relational anxiety through sexual interactions with individuals who will not reject them (e.g. children). As a result, it is hypothesized that anxiousambivalent attachment is a predictor to the development of pedophilia.
MISATTUNEMENT AND THE PEDOPHILE

According to Attachment Theory, the core of healthy functioning is the ability to regulate one’s affect. Conversely, the core of pathology is affect misattunement. Affect regulation begins in infancy when the primary caregiver resonates, responds and reflects the child’s emotions. An example of affect attunement is the mother responding to an infant’s laugh, with a reciprocal smile. When affect misattunement occurs (i.e. a mother responds to a smiling baby with anger and frustration), the child does not know how to regulate his own affect. Affect regulation requires two abilities in both childhood and adulthood: the capacity to self-soothe and the capability to seek others for emotional support. Unfortunately, the “misattuned” pedophile, does not know how to self-soothe nor does he possess the confidence to seek outside assistance. The affect misattunement is so severe that many times a normal behavior, such as a child walking around the house

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in her pajamas, may be misinterpreted as a sexual advance. Therefore, due to a lack of affect regulation, pedophiles do not typically have the ability to accurately perceive victim affliction and respond with empathy (Schwartz, 1997). Attachment theory assists in explaining how early infant and childhood interactions are predisposing factors to the development of pedophilia, specifically with regards to attachment styles, a lack of empathy, and affect misattunement. However, a question persists. If pedophilia is caused, in part, because of insecure attachments, why don’t all insecurely attached adults develop pedophilia? This question may be further explained through Self-Psychology.
SELF-PSYCHOLOGY

Attachment Theory provides a strong theoretical foundation for understanding the pedophilic psyche and its inception in infancy. However, Kohut’s theory of Self-Psychology is a fluid model of development that assists in conceptualizing pedophilia from early infancy and childhood (grandiose and idealizing poles) through adolescence and adulthood (twinship pole). Kohut’s model specifically addresses the theoretical gap between infancy affect misattunement and the development of pedophilia in adulthood through the concept of twinship. In order to fully conceptualize pedophilia through Kohut’s theory of Self-Psychology, a brief overview of the model will be provided followed by the conceptualization of the development of pedophilia through the grandiose pole, the idealizing pole and the twinship pole. Finally, the pathological manifestation of pedophilia will be discussed.
KOHUT’S MODEL OF SELF-PSYCHOLOGY

Within Kohut’s theory, a child possesses healthy narcissistic needs that must be met, including validation, reinforcement of self-esteem and communion (Goldberg, 1985). In order to meet these needs and achieve the consolidation of the self, the child must walk three pathways of development, which Kohut deemed the grandiose pole, the idealizing

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pole and the twinship pole. The child’s needs received through each pole must basically be met. Otherwise, the child will experience a sense of shame that is theorized to be a primary factor in the development of pedophilia, which will later be addressed. Relationships are a key concept within Kohut’s theory as the child’s identity is essentially developed through selfobjects (Kohut & Ornstein, 1991). Selfobjects may be defined as the persons or things that are experienced as part of the self. They are also the parts of the primary caregiver that the child internalizes in order to develop a unique self. The internalization of selfobjects results in a cohesive self. However, if selfobjects are not internalized, the result is fragmentation and a continuous hunger for selfobjects. For the pedophile, children serve as the selfobjects for which they hunger. Thus, pedophilia serves to stabilize the fragmenting self as a result of not internalizing the needed selfobjects.
GRANDIOSE POLE

In Kohut’s model, the grandiose pole represents the “ambitions, goals and ideals” that comprise the self (Goldberg, 1988). A child has these inborn talents and potentialities; however, it is the responsibility of the primary caretaker to respond to the child’s needs and mirror him so his talents, goals and ideals are self-actualized. Thus, mirroring develops into self-esteem and assertiveness, which results in ambitions, power and success as an adult. However, in the case of a pedophile, it is theorized that within the grandiose pole he was not mirrored properly. The child desired to feel special, but he did not feel the beauty and splendor within because his essential goodness was not reciprocally mirrored; consequently, he began to lose the possibility of developing a true self or an independent center of initiative. The child then developed a sense of shame for not having his goodness mirrored back to him. Therefore, the potential pedophile is unable to develop a healthy level of self-esteem and he loses the ability to develop ambitions, power and success in terms of having healthy relationships. The pedophile begins a journey to have selfobjects reflect back to him his goodness and grandiosity. As his peers will not reflect

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his goals, ideals and ambitions due to the shame he exudes, it is theorized the pedophile seeks children to reflect back to him his goodness.
IDEALIZING POLE

The second pole identified in Kohut’s model is the idealizing pole (Goldberg, 1998). The purpose of attaining and maintaining an idealized selfobject is to receive soothing and achieve affect regulation. Through an idealized parent imago the child is soothed and feels safe. Once the child develops the capacity to self-soothe, he becomes a cohesive and stable self worthy of admiration and respect. In the case of a pedophile, it is theorized that the child did not see the strength and wonder outside of himself. He did not have someone strong, calm, and wonderful to idealize and merge with to fulfill his safety needs. His primary caregiver was not psychologically or physically present consistently for him to take in the selfobject and feel safe and strong. This likely affected his ability to develop affect attunement because his feelings of meekness were not counteracted by the caregiver’s presence. When a child does not have an idealized parent imago, he begins to lose the ability to develop tension regulation and self-soothing, which also inhibits his development into an individual worthy of respect and admiration. It is hypothesized that the potential pedophilic child experienced transmuting internalization, but in unmanageable doses. The primary caregiver or selfobject continuously disappointed the child leading him to selfsoothe and manage his emotional needs in a dysfunctional way, which results in anger and aggression. According to Goldberg (1988), aggression is a symptom derived from an un-empathetic environment. The potential pedophilic child begins to experience a sense of narcissistic rage as a result of his interpersonal connectedness needs not being met; however, this rage remains in the preconscious. Thus, the child develops into the “tragic man” as the potential pedophile feels empty, lacks emotional connection and is void of ideals and heroes.

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As an adult, affect misattunement will make the potential pedophile’s relationships superficial and essentially unsatisfying, leading him to search for fulfillment through children (Goldberg, 1985). Consequently, children become the selfobjects that the pedophile attempts to internalize so he in turn, feels powerful and omnipotent, masking his insecurity, fear, and shame. Thus, the pedophile begins to use children as selfobjects to regulate his affect from the anxiety he frequently experiences. He also uses children as selfobjects as a means of externalizing his narcissistic rage. Finally, the pedophile uses children to fulfill his needs of being respected and admired. He may falsely achieve these needs through children.
TWINSHIP POLE

In Kohut’s model of Self-Psychology, the twinship pole is the third pole of the tri-polar self, required to achieve identity cohesion. The basic premise of the twinship pole is individuals feel an essential likeness, belonging and security with peers. Twinship is typically achieved in the latency stage when the individual discovers his own goals and ideals, which are recognized and appreciated by his peers (Banai, Shaver, & Mikulincer, 2005). However, in the case of a pedophile, he cannot experience true twinship among his peers because he lacks the self-esteem and self-soothing capabilities to develop genuine relationships. Furthermore, he feels a deep sense of shame that inhibits his ability to be genuine with others. As a result of the inability to achieve true twinship, the pedophile seeks children because he does not feel worthwhile or confident among his peers. It is theorized that the relationship with children assists the pedophile in gaining a sense of control over the feelings of shame and powerlessness he likely experienced as a child at the hands of an adult (Finkelhor & Araji, 1986; Schwartz, 1997). Consequently, the cognitive distortions many pedophiles exhibit is merely a defense mechanism employed to cover the shame and justify prepubescent sexual advances.

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PATHOLOGICAL PEDOPHILIA MANIFESTATION

It is hypothesized that pedophiles have developed a primary disorder of the self, as they have given up hope that they will ever receive empathy or that their archaic needs to internalize an idealized object will ever be met. According to Goldberg (1998), unintegrated lust and aggression are products of a pathological breakdown of the self. Consequently, it is believed that pedophiles experience a fragmentation and breakdown of the self that develops into narcissistic behaviors. These narcissistic behaviors are manifested through using children as a way of fulfilling their need to be in control, being perceived as admirable, and achieving a likeness they cannot obtain through peers (Banai, Shaver, & Mikulincer, 2005, p. 226). The end result of the aforementioned difficulties in meeting the needs of the grandiose pole, idealizing pole, and twinship pole is a chronic, archaic yearning for selfobjects. The pedophile seeks to fulfill these selfobject needs through children. While non-offending individuals have likely not fulfilled all their selfobject needs, it is theorized that in the case of a pedophile, the extent to which their selfobject needs have not been met is severe. This has resulted in the pathological development of pedophilia. However, while Self-Psychology provides a developmental perspective, there is a neurobiological basis that must be addressed.
NEUROBIOLOGY OF PEDOPHILIA

Neurobiology is complementary to Self-Psychology and Attachment Theory because it scientifically supports some of the presuppositions of the behavioral theories and their application to pedophilia. Significant research conducted on the biological and neurological differences of pedophiles and non-offenders is significant. According to Rice, Harris, Lang & Chaplin (2008), “Neuro-developmental disruption forms an important cause of pedophilia. Men with pedophilia have lower IQ scores, have a childhood head injury, have elementary school academic problems. . .all indirect indicators of neurodevelopmental perturbation” (p. 409).

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Furthermore, an interference of brain development has been linked to insecure attachment and cognitive distortions about the self, others, and the world (Wood & Riggs, 2009). Therefore, an application of neurobiology to pedophilia will be conducted to further explain this disorder that is misunderstood. The neurobiological research about the following brain areas and their impact on pedophilia will be discussed: amygdala, the temporal lobes and the frontal lobe and the orbitofrontal cortex.
AMYGDALA

The amygdala plays a significant role in the development of pedophilia. The amygdala is the “central neural hub” of emotional experience as it is a vital part of the limbic system (Cozolino, 2002). The amygdala also contains the implicit attachment schemas developed in infancy and childhood. Consequently, it has the potential to be a significant factor in the development of pedophilic thoughts and urges. A study was conducted by Schilz, Witzel, Northoff, Zierhut, Gubka, Fellmann, Kaufmann, Tempelmann, Wiebking, & Bogerts (2007) that postulated there was a relationship between amygdalar impairment and pedophilic offenses. The authors found that pedophile perpetrators had considerably smaller amygdala volume on the right side of the brain. Consequently, the right side of the amygdala affects sexual functioning more than the left (Cozolino, 2002). The study also found that there was gray matter in the amygdala, which could likely have an effect on sexual development. As a result, the authors hypothesized that developmental or environmental disturbances occurred at critical periods in the pedophiles’ lives While scientific research has shown a correlation between pedophilic desires and amygdala volume and gray matter, it can be further theorized that the early infant and childhood interactions of attachment have become implicit memories. As a result, they serve as unconscious roadmaps to emotional dysfunction and misattunement.

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TEMPORAL LOBES

The reduced volume of the amygdala is a significant predisposing factor to the development of pedophilic desires; however, the temporal lobes also appear to affect the development of pedophilic sexual attraction. According to Suchy, Whittaker, Strassberg & Eastvold (2008), sexual attraction to children is mediated by temporal lobe irregularities. Temporal lobes are the center of the social brain as they process information from different senses and integrate the information with affective information obtained from the amygdala (Cozolino, 2002). Temporal lobes are also associated with auditory, visual and sensory skills. As such, research has shown that pedophiles have exhibited deficits in semantic knowledge and verbal learning (Suchy, Whittaker, Strassberg, & Eastvold, 2008). Evidently, there appears to be a significant correlation between damage to social brain structures, such as the temporal lobes and amygdala, and sexual dysfunction or pedophilic sexual attraction.
THE FRONTAL LOBE AND THE ORBITOFRONTAL CORTEX

While the aforementioned brain structures may contribute to the development of pedophilic sexual attraction, damage to such structures does not explain why an individual would act on impulses. However, this question may be answered by examining frontal lobe impairment and its impact on pedophilia. The frontal lobe is the executive of the brain and it affects an individual’s ability to maintain selfcontrol, control impulses, and make shifts in attention (Cozolino, 2002). Stone and Thompson (2001) conducted a study on the frontal lobe of pedophiles and rapists and found significant impairment in the majority of sex offenders. As a result, damage to the executive functioning system of the brain would inhibit a pedophile’s ability to control his impulses. Furthermore, as the orbitofrontal cortex is located in the frontal lobes, damage to this brain structure could also result in increased impulsiveness, sexual disinhibition and inappropriate social behavior (Cozolino, 2002, p. 138). While this does not absolve pedophiles from responsibility, it does provide an understanding of the behaviors. As neurobiology provides a biological

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understanding to pedophilia, it does not explain the social and demographic factors that may impact pedophilic behavior.
DIVERSITY ISSUES

Neurobiology affects the way in which the brain functions and experiences attraction; however, there are numerous other biological, social, and environmental factors that may influence an individual’s development of pedophilia. Specific diversity issues, such as gender and ethnicity have been identified in literature as impacting the motivation of pedophilic desires (Gannon & Rose, 2008). Consequently, these diversity issues will be addressed.
GENDER

Within the context of sexual offenses, men are stereotypically viewed as the offenders and women are perceived as the victims (Gannon & Rose, 2008). Statistics confirm the stereotype as 89.3% of pedophiles are male and 10.7% are female (Peter, 2009). Nevertheless, it has been hypothesized that the statistics of female perpetrators are drastically underreported because women are socially viewed as more nurturing and caring. As a result, benign behaviors women exhibit toward children may be sexual in nature (i.e. bathing a child in a sexual way). Since research has focused on men as sexual offenders, there is little information available regarding the motivational differences between men and women. However, statistics measuring female offenses and traumatic histories shed a different light on female sexual offenders. Approximately 80% of women charged with sexual assault had been historically sexually abused (Lewis & Stanley, 2000). Also, 95% of female offenders were victims of either physical or sexual abuse (Schwartz, 1995). These statistics are drastically different than the 43% of male pedophiles who reported sexual abuse (Sawle & Colwell, 2001). Consequently, the motivating factors in male and female pedophilic offenses appear to differ.

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ETHNICITY AND CULTURE

In addition to gender factors, ethnic and cultural factors must also be considered in conceptualizing the motivations for pedophilia. Few studies have focused on the ethnic differences of sexual offenders and pedophiles; however, Ward, Hudson & Marshall (1996) purport that social and cultural factors likely have a “major influence” on an individual’s ability to form intimate relationships, thus affecting their sexual attractions and behaviors. A national study conducted on the recidivism of child molesters found that pedophiles were predominantly non-Hispanic Caucasian males age 30 or older (Langan, Schmitt, Durose, 2003). Furthermore, 20% of pedophiles were black men, and 3% were Hispanic (Langan, Schmitt, Durose, 2003). The predominance of Caucasian pedophiles could be a result of American individualistic culture. In addition, two ethnicities were identified by Schwartz (1997) as requiring additional attention for understanding pedophilic motivations: Hispanic and American Indian. According to Schwartz (1997) the “machisimo” attitude exhibited in Mexican culture is associated with sex offending. More specifically, within Hispanic culture there is a concept called “obediencia afiliativa,” which means filial obedience. This concept has been known to be used by fathers to coerce younger family members into sexual relationships. Also, within the American Indian population Schwartz (1997) theorized that sexual offending may be a displacement of violence and anger as a result of poverty and dependency on the federal government. While only two primary ethnicities were addressed, it appears evident that ethnic and cultural factors impact the perception and motivation of pedophilia. Within American society the minority is frequently overlooked. Overlooking such factors and their association with pedophilia, only places more children in harm’s way. It is essential that research conducted and interventions developed for pedophiles are inclusive of diversity factors.

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TREATMENT

Currently, within the sex offender treatment field 80% of programs focus on cognitivebehavioral treatments and relapse prevention. These interventions are aimed at reducing the possibility of recidivism (Saleh & Guidrey, 2003). However, these interventions are a onesize-fits-all model, which is not conducive to the treatment of all sex offenders, specifically pedophiles from diverse backgrounds. Furthermore, these interventions do not address the affect misattunement and insecure attachment styles pedophiles have developed (Hudson, Ward, Marshall, 1996). As a result, the following treatment plan is aimed to address the specific needs of pedophiles deriving from Attachment Theory, Self-Psychology, neurobiology and diversity issues. The following generalized treatment approaches will be addressed: initial referrals, beginning stage of therapy and the middle stage intervention. Finally, adjunct therapies will be discussed as enhancements to the treatment plan.
REFERRALS

Upon receiving an individual with pedophilia, two referrals will be made in order to provide holistic treatment. Due to the correlation between neurological development and pedophilia, the individual will first be referred for cognitive and psychological testing. The second referral will be made to a psychiatrist for psychopharmacological treatment. Research has shown that anti-androgens and serotonin reuptake inhibitors are helpful in controlling aggressive sexual deviancy (Schwartz, 1995).
BEGINNING STAGES OF THERAPY

The beginning stage of therapy is important as trust and the therapeutic alliance is developing. Due to the insecure attachments and narcissistic injuries pedophiles may have experienced in infancy and childhood, the beginning stage of therapy is crucial for the successful treatment of the pedophile. Developing rapport and a therapeutic alliance is necessary in order to reach the affective internal working model of the client. The beginning stages of therapy should not be rushed as the therapeutic relationship can serve as a “template” for the development of secure attachment (Kear-Colwell & Boer,

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2000). The therapist may serve as the secure base for the client as the client may begin to feel safe to explore his emotions and affective states. In addition to serving as a secure base and the therapeutic alliance serving as a template for new attachments, the therapist may also serve as mirroring, soothing, and twinship selfobjects. Mirroring in the beginning stages of therapy can build rapport if the therapist is able to validate and reflect back to the individual his feelings and emotions. The therapist may also provide empathetic attunement, which is crucial when treating the pedophile because of his narcissistic wounds. Finally, minimal and carefully selected selfdisclosure may also be done in order to create a sense of twinship. Twinship needs are essential as pedophiles have a tendency to seek children for emotional needs because they do not feel worthy among their peers.
MIDDLE STAGE OF TREATMENT: THE ROCKWOOD PROGRAM

In addition to individual therapy, the client will be placed in group therapy during the middle stage of treatment. The rationale for group therapy is because sexual deviancy is similar to the psyche of an individual with an addiction, specifically with regards to “denial, guilt and secrecy” (Schwartz, 1995). These are the characteristics that make therapy with pedophiles particularly difficult. According to Schwartz, “Because these offenders often lie, minimize, and rationalize their behavior, it is quite a task for a lone therapist to muster the strength or the evidence to confront their defenses. Group members are able to recognize their own patterns and may provide confrontation, which is more effective than the tactics of the therapist” (p. 451). Therefore, in lieu of traditional treatments, the Rockwood Program is proposed as it focuses on the expression of emotion and the development of affect regulation in a group setting (Marshall, Marshall, Serran & O’Brien, 2008). The program includes various topics aimed at treating pedophilia from a holistic perspective. Group topics include the following: creating an autobiography, accepting responsibility, creating an

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offense pathway, developing coping skills and self-management skills and processing relationship and sexual issues.
TREATMENT ADJUNCTS

While the Rockwood Program is proposed as the primary treatment in addition to individual therapy, adjunct treatments will also be recommended to prevent relapse. These treatments include CBT, as it addresses the cognitive distortions that many pedophiles possess. Furthermore, CBT has been effective in reducing trauma symptoms for the pedophile sexually abused as a child (Burton, 2008). Finally, behavioral techniques may be used to “alter sexual arousal” (Schwartz, 1995). While these techniques have proven beneficial in reducing recidivism, they do not address the primary cause of pedophilia.
CONCLUSION

Child molesters have a deep-rooted fear of intimacy and close relationships, likely stemming from early infant and childhood interactions (Sawle & Colwell, 2001; Ward, Hudson, & Marshall, 1996). Pedophiles have the right to effective treatment for the promotion of their own recovery and also for the benefit of their otherwise potential victims (Ricci, 2004). In order to utilize an effective treatment for pedophilia, a strong theoretical foundation for pedophilia must be conceptualized. Therefore, this paper employed the use of Attachment theory to explain the misattuned pedophile. SelfPsychology described sexual deviancy as unintegrated lust and aggression as a result of the pathological breakdown of the self (Goldberg, 1998). In addition, neurobiology explained why pedophiles may act on their sexually deviant impulses. Diversity issues such as gender and ethnicity were also discussed within the context of their impact on motivation. Consequently, a holistic perspective of the pedophile was conceptualized. The NASW Code of Ethics states that the advancement of the most effective practices, obtained through relevant theoretical application, is essential to maintain the dignity and worth of the person being treated. While the crimes pedophiles commit do not

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require approval, the individuals as humans deserve respect and the best attempts to create environments in which recovery is fostered.

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REFERENCES Applegate, J., & Shapiro, J. (2005). Neurobiology for clinical social work: theory and practice. New York, NY: W.W. Norton and Co. Banai, E., Shaver, P., & Mikulincer, M. (2005). “Selfobject” needs in Kohut’s Self Psychology.
Psychoanalytic Psychology, 22(2), 224-259.

Bartholomew, K. (1990). Avoidance of intimacy: An attachment perspective. Journal of Social
and Personal Relationships, 7, 147-178.

Berzoff, J., Flanagan, L.M., & Hertz, P. (2008). Inside out and outside in. 2nd edition. Northvale, NJ: Jason Aronson Bowlby, J. (1969). Attachment and loss, volume 1: Attachment. NY: Basic Books Bowlby, J. (1973). Attachment and loss, volume 2: Separation. NY: Basic Books Bretherton, I. (1992). The origins of attachment theory: John Bowlby and Mary Ainsworth.
Developmental Psychology, 28(5), 759-775.

Burton, D.L. (2008). An exploratory evaluation of the contribution of personality and childhood sexual victimization to the development of sexually abusive behavior. Sexual Abuse: A
Journal of Research and Treatment, 20(1), 102-115.

Cozolino, L. (2002). The neuroscience of psychotherapy. New York, NY: W.W. Norton and Co. Dabbs, J.M., Frady, R.L., Carr, T.S. et. Al. (1987). Saliva testosterone and criminal violence in young adult prison inmates. Psychosom Med, 49, 174-182. Finkelhor, D., & Araji, S. (1986). Explanations of pedophilia: A four factor model. The Journal
of Sex Research, 22(2), 145-161.

Gannon, T., & Rose, M. (2008). Female child sexual offenders: Towards integrating theory and practice. Aggression and Violent Behavior, 13, 44-461. Goldberg, A. (Ed). (1985). Progress in self psychology (Vol. 1). New York, NY: The Guildford Press. Goldberg, A. (Ed). (1998). The world of self psychology: Progress in self psychology,
volume 14. Hillsdale, NJ: The Analytic Press.

Jespersen, A., Lalumiere, M., & Seto, M. (2009). Sexual abuse history among adult sex offenders and non-sex offenders: A meta-analysis. Child Abuse & Neglect,
33,179-192.

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Kear-Colwell, J., Boer, D.P. (2000). The treatment of pedophiles: Clinical experience and the implications of recent research. International Journal of Offender Therapy and
Comparative Criminology, 44, 593-605.

Kilmann, P., Sabalis, R., Gearing, M., Bukstel, L., & Scovern, W. (1982). The treatment of sexual paraphilias: A review of the outcome research. The Journal of Sex
Research, 18(3), 193-252.

Kohut, H. & Ornstein, P (Ed). (1991). The search for the self, (Vol IV). Madison, CT: International Universities Press Langan, P., Schmitt, E., Durose, M. (2003). Recidivism of sex offenders released from Prison in 1994. (NCJ 198281). Washington, D.C.: U.S. Department of Justice. Lewis, C.F., & Stanley, C.R. (2000). Women accused of sexual offenses. Behavioral Sciences
and the Law, 18, 73-81.

Lyn, T.S., & Burton, D.L. (2004). Adult attachment and sexual offender status. American
Journal of Orthopsychiatry, 74(2), 150-159.

Marshall, W., Marshall, L., Serran, G. & O’Brien, M. (2008). Sexual offender treatment: A positive approach. Psychiatr Clin N Am, 31, 681-696. McCormack, J., Hudson, S.M., & Ward, T. (2002). Sexual offenders’ perceptions of their early interpersonal relationships: An attachment perspective. The Journal of Sex Research,
39(2), 85-93.

Peter, T. (2009). Exploring taboos: Comparing male- and female-perpetrated child sexual abuse.
Journal of Interpersonal Violence, 24, 1111-1130

Ricci, R. (2004). Trauma resolution treatment as an adjunct to standard treatment for
sexual offenders. (Doctoral dissertation, Virginia Polytechnic Institute and State

University, 2004). Retrieved from ProQuest Dissertation Database. Rice, M., Harris, G., Lang, C., & Chaplin, T. (2008). Sexual preferences and recidivism of sex offenders with mental retardation. Sex Abuse, 20, 409-427 Saleh, F., & Guidry, L. (2003). Psychosocial and biological treatment considerations for the paraphilic and nonparaphilic sex offender. J Am Acad Psychiatry Law, 31, 486-93.

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Sawle, G., & Colwell, J.K. (2001). Adult attachment style and pedophilia: A developmental perspective. International Journal of Offender Therapy and Comparative
Criminology, 45(32), 32-50.

Schilz, K., Witzel, J., Northoff, G., Zierhut, K., Gubka, U., Fellmann, H., Kaufmann, J., Tempelmann, C., Wiebking, C., Bogerts, B. (2007). Brain pathology in pedophilic offenders. Arch Gen Psychiatry, 64, 737-746. Schwartz, B. (1995). The sex offender: Corrections, treatment and legal practice, (Vol. I). Kingston, NJ: Civic Research Institute. Schwartz, B. (1997). The sex offender: Corrections, treatment and legal practice, (Vol II). Kingston, NJ: Civic Research Institute. Schwartz, B. (1999). The sex offender: Corrections, treatment and legal practice, (Vol III). Kingston, NJ: Civic Research Institute. Stone, M.H., & Thompson, E.H. (2001). Executive function impairment in sexual offenders. The
Journal of Individual Psychology, 57(1), 51-59.

Suchy, Y., Whittaker, W., Strassberg, D., & Eastvold, A. (2009). Neurocognitive differences between pedophilic and nonpedophilic child molesters. Journal of the International
Neuropsychological Society, 15, 248-257.

Ward, T., Hudson, S., Marshall, W. (1996). Attachment style in sex offenders: A preliminary study. The Journal of Sex Research, 33(1), 17-26. Wood, E, & Riggs, S. (2009). Adult attachment, cognitive distortions, and views of self, others, and the future among child molesters. Sex Abuse, 21(1), 375-390.

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Cross-Cultural Skills Building Training Program for the Program for Torture Victims Clinical Staff
LORENE GINGERICH
Evaluation of Research: Community Organization, Planning and Administration Professor Jacquelyn McCroskey

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INTRODUCTION AND BACKGROUND

Program for Torture Victims (PTV) is a non-profit organization in Los Angeles with the mission of providing services “to alleviate the health consequences and suffering of state sponsored torture by providing medical, psychological and case management services to survivors of torture” (Program for Torture Victims, n.d.). PTV is the oldest torture treatment program in the U.S., and the specific services PTV offers to accomplish its mission are psychological evaluation and counseling, medical evaluation and treatment, forensic services (including forensic medical and psychological evaluations and expert witness testimony in federal immigration court), case management and support groups. The agency does not limit its services to the refugee community, but also works closely with the community to do training, public education, advocacy and legislative work (Program for Torture Victims [PTV], 2009). In order to provide specialized services, PTV has an extremely knowledgeable and skilled staff. Dr. Jose Quiroga of Chile and Ana Deutsch of Argentina are torture survivors who co-founded PTV in 1980 (Lopez, 2006). Both Dr. Quiroga and Ana Deutsch have pioneered the treatment of torture survivors in the United States and remain as active staff in the agency (Dr. Quiroga, Medical Director and Ana Deutsch, Clinical Director). PTV is unique in the national community of torture treatment centers because it was the first program of its kind in the United States, and all services are free of charge to eligible clients, persons who have experienced state sponsored torture living in the greater Los Angeles area. PTV is almost the only agency in the nation to provide in-house medical, psychological and case management services, facilitating its ability to provide integrated interdisciplinary care and longer term services to survivors. PTV is unique in its geographical location because it is the only torture treatment program in the greater Los Angeles region. PTV serves clients from five counties, including Los Angeles, Orange, San Bernardino, Ventura and Riverside. Being the only torture treatment program in greater Los Angeles, PTV has served approximately one

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thousand clients since 2000 (PTV, 2009). PTV provides services to survivors of statesponsored torture who come to the U.S. seeking asylum from over 65 countries. To name a few, PTV serves clients from Africa, Asia, the former Soviet Union, the Middle East and Latin America. However, the demographic population at PTV is constantly changing, along with the world’s political, social and economic dynamic. PROGRAM EVALUATION To respond to the constantly changing environment in the world and to diverse clients PTV serves, PTV gives regular training on cross-cultural skills building in order to promote continuing efforts for cultural awareness among all community providers. Then, the program to be evaluated is the existing cross-cultural skills building training PTV staff gives to the community that will be regularly incorporated into in-house staff training. In-house cross-cultural discussions occur regularly during weekly PTV staff meetings, but there is no formal training program or tracking mechanism. PTV does however have a format for training. PTV staff gives training to the Department of Homeland Security Los Angeles Asylum Office, immigration judges, lawyers, local physicians, mental health providers, social service agencies, institutions of higher education, and community groups. Community training is provided by PTV staff members as advocacy and public education on the unique cultural practices and worldviews of refugees, especially PTV clients (American Psychology Association, 2003). The PTV clinical staff has created several different training formats, handouts and PowerPoint presentations for this community training. The most recent and comprehensive training was created in 2007 called “Building Cross-Cultural Clinical Skills in Providing Mental Health Services to Refugee Survivors of Torture” (Berthold & Durocher, 2007). The goal of this training is to provide a cross-cultural skills building training to professionals in the community to help them become more aware of cultural differences and how these differences may impact their professional practice. The training objectives are to increase the attendees’ knowledge of cultural diversity by providing

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definitions, statistics and the range of experiences and challenges refugee populations experience in relation to mental health in Los Angeles County. The training extensively reviews the approaches and considerations practitioners must exercise when working with refugees including the following: three phases of traumatization, rape, assessment and interviewing techniques, diagnostic and treatment considerations, burn out, counter transference, vicarious traumatization and outreach approaches. Healy (2008) suggests that learning about cultures to improve services is not sufficient, but that further attention is needed in cultural competence practice to increase knowledge on international populations within nations and knowledge on the oppressive forces that cause PTV clients to flee from their countries. Then, focusing on cultural competency can expand PTV’s training program. In order to expand the training program to focus on cultural competency, a definition for cultural competency must be established. There are varying definitions of cultural competency (Lo & Fung, 2003; Alvarez & Chen, 2008; D.W. Sue & Torino, 2005; S. Sue, 1998) but the overall goal of cultural competency is to work for social justice and empowerment of clients through learning about cultures, skills or interventions and the process involved (Gutierrez, Fredricken & Soifer, 1999; Sue, Zane, Hall & Berger, 2009). Falicov (1995) and Sue et al. (2009) explain that it is difficult to integrate changed attitudes and behaviors, competency skills and knowledge into practice. Therefore, the training needs to incorporate education on specific cultural backgrounds (ethnic and religious) and provide tools for incorporating this knowledge into practice. PTV clinical and medical staff members have competency skills in their practice because of their extensive work and experiences with international populations. According to Client Outcome Study from 2000-2008 (Program for Torture Victims, 2009), many of the torture survivors seeking PTV services have experienced multiple traumas and without treatment may experience relapses in symptoms such as pain (somatic complaints),

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anxiety, depression, and withdrawal from normal activities and absence from work. Many have also fled to the US without their normal social networks and support and find it difficult to establish relationships with community organizations and resources. It is crucial for the case manager and clinical staff to work with the client to identify communities in Los Angeles with connections to their religious, ethnic or refugee groups to extend their social network. Lastly, the Client Outcome Study demonstrates that clients have benefited from PTV staff members’ cultural sensitivity and flexible approach to services (Program for Torture Victims, 2009). Since treatment of torture victims requires flexibility and a heightened cultural awareness, there is a great need for the clinical and medical staff to be even more culturally competent. There are numerous cultural backgrounds and unique worldviews that practitioners have not worked with and do not have cultural competency skills for their practice. As conflicts and wars continue to break out around the world there is a growing need for PTV staff to continue improving their knowledge of cultures. The current cross-cultural clinical skills training uses a skills and cultural adaptation model focusing on skills or strategies learned in working with culturally diverse clients and provides training in developing psycho-therapeutic competencies (Whaley & Davis, 2007; Sue et al., 2009). In order to expand the current training for PTV staff members, PTV needs to expand its delivery method to include translating materials, provide more education on culturally appropriate respect, and provide interventions in cultural contexts (Sue et al., 2009). For example, PTV does not have agency materials translated into other languages and relies on interpreters to translate the material. This is problematic because often the meaning of the question or original material can get lost in translation (M. Berthold, personal communication, September 30, 2009). PTV staff has knowledge and experiences with many cultures but it would enrich the agency’s services to do more staff training on culturally appropriate respect (formal language, greetings, titles, communication, cultural standards and practices). Finally, providing interventions in

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a cultural context is difficult because of institutional and Western cultural constraints (Sue et al., 2009). For example, clinical and medical staff must provide evaluations and testimony for federal court that is in the context of Western therapy and medical language. Interventions like cultural ceremonies, such as pouring libations for ancestors or lighting candles, are not interventions that are legitimized in court (Sue et al., 2009). Therefore there is a tendency for staff to practice with cultural awareness while still providing “traditional Western” therapy. Expanding training in cultural competency to include skills building and culturally adaptive interventions will enable PTV staff to provide even more valuable and needed services to its clients. The information PTV learns from training its own staff members can inform new training given to other service providers on culturally appropriate techniques and interventions for practice.
PROBLEM IDENTIFICATION

Torture is a social problem in countries around the world, including the United States. In 2000, it was reported that 150 nations practiced torture or maltreatment (Amnesty International, 2000). Despite the increased visibility and prevalence of torture, there remains relatively little scientific data on the effects and treatment of torture (Quiroga & Jaranson, 2005). Then, in order to demonstrate the medical and psychological impact torture has on individuals, it is important to establish a definition of torture. Torture is defined by many entities in different ways. Amnesty International was the first organization in 1973 to give a broad definition of torture from a political and operational point of view and later in 1975 the World Medical Association (WMA) adopted a similar definition (Quiroga & Jaranson, 2005). Both definitions of torture include the deliberate or systematic infliction of mental or physical pain by force of another person in order to gain information, a confession or for any other reason (Amnesty International, 1975; Amnesty International, 1994). These definitions from Amnesty International and WMA

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were used from 1973-1984 until the United Nations (UN) Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) (Office of the United Nations High Commission for Human Rights, 2007). In 1984 CAT adopted the definition for torture as:
…any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purpose as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed, or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by, or at the instigation of, or with the consent or acquiescence of, a public official or other person acting in an official capacity.

This definition from CAT is the official definition for torture that was adopted and ratified by 210 countries on April 23, 2004 (Quiroga & Jaranson, 2005). The purpose for ratifying and adopting a definition for torture was not to group, label or pigeonhole individuals but as an accountability measure for those who participate in torture. Then, the official definition of torture fails to capture who experiences torture because torture survivors do not have a specific profile. They are men, women, children, rich, poor, educated, uneducated, farmers and businesspeople (Fabri, 2001). For this paper the official CAT definition for torture will be used as any kind of physical or mental pain or suffering experienced by individual for the purpose of information or based on discrimination by a public official or third party acting on behalf of the official. Following the ratification of CAT and the total number of refugees in the world reaching nearly 16 million (U.S. Department of State, 2009) there was increased demand for the U.S. and other nations to respond to unsettled refugee populations. In response to the growing number of refugees in the world, U.S. Congress passed the Torture Victims

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Relief Act of 1998 (TVRA), that recognized there was a significant number of refugees, asylees, and asylum seekers entering the United States who have suffered torture (U.S. Department of Health & Human Services, 2009). TVRA was a monumental act passed by Congress because despite scarce research on torture victims among refugee populations (Quiroga & Jaranson, 2005), the legislation provided funding to treatment centers for treatment programs and services. Before TVRA torture treatment programs had little to no funding for services and the majority of centers were volunteer based. PTV received the first cycle of TVRA funding in 2000 and continues to rely heavily (64% of its overall funding) on this federal grant. However, one year after dispersing federal funds to eligible torture treatment centers, the terrorist’s attacks on September 11, 2001 posed new threats to immigrant populations, affected US policy on security and increased the need for services in the refugee populations. New US policies like the USA PATRIOT Act (Uniting and Strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism) were meant to increase US security. However, it posed new threats to immigrants because it was applied retroactively calling for deportation of immigrants known to support terrorist organizations (Matthews, 2002). The Patriot Act increased the need for services because it increased the number of detentions and deportations in the immigrant and refugee populations (Healy, 2008). Despite PTV receiving federal funding for medical and clinical torture treatment services, during the eight years following 9/11 the agency has found itself providing more and more forensic services to refugees who have been detained and even tortured under this new US policy.
LITERATURE REVIEW FOR PROPOSED INTERVENTION

According to the U.S. Refugee Admissions Program (USRAP) report of the 48,217 refugees admitted into the U.S. in 2007, 6,699 (13.89%) resettled in California (Quiroga & Jaranson, 2005; U.S. Department of State, 2009). California had the

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highest number of refugee arrivals of any state in the U.S, with Florida (2,619) and New York (2,978) following California. Additionally, of the 6,699 refugees who resettled in California, 4,645 (69%) resettled in the five counties that PTV serves (California Department of State Office of Admissions Refugee Processing Center, 2009). The Los Angeles Federal Immigration Court had the highest number (4,064) of asylum applicants in all of California’s counties (Program for Torture Victims, 2009). Therefore, the treatment of torture survivors is relevant to the greater Los Angeles area because a majority of the refugees entering the US have resettled in California, but in particular within the communities and neighborhoods that Program for Torture Victims (PTV) serves. According to the Los Angeles County Census (2000) the demographics for Los Angeles County foreign-born populations included people from Asia (29.6%), Africa (1.2%), Oceania (.4%), Latin America (62.1%) and Mexico (44.2%). Similarly, statistics from the Client Outcome Study 2006-2007 indicated that PTV serves clients from Africa (52%), Asia (27%), the former Soviet Union (15%), the Middle East (4%) and Latin America (2%). There are many similarities and differences in the percentages of Los Angeles County and the populations PTV serves. The first noticeable difference in statistical data can be contributed to the census information from 2000 and PTV data collection from 2006-2007. Also, one must take into account that differences in data can be attributed to the changes occurring politically, socially and economically from 2000-2007. Despite the differences in statistics or demographics, the overall impact of these statistics demonstrates that Los Angeles is serving significant numbers of immigrants entering this country, with the majority of these refugees resettling in communities PTV serves. Likewise, client statistics from 2006-2007 indicate that on average PTV serves nearly 300 clients per year (including approximately 90-100 new clients). Typically the population of clients is evenly split between males and females. The age range of clients who entered PTV in 2007 is between the ages of 5-66, where the average age is 37.6 (Program

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for Torture Victims, 2009). Since 2000, PTV has served approximately one thousand individuals seeking asylum in the U.S. with psychological, medical, case management and legal services. In order to demonstrate the full spectrum of services PTV provides, one must understand US policy and what the process for seeking asylum may look like. The US policy on asylum states that individuals from any country may seek protection from prosecution or fear of prosecution on the basis of race, religion, nationality, membership in a particular social group, or political opinion (U.S. Citizenship & Immigration Services, 2009). After the PATRIOT Act (2001) gaining asylum in the U.S. has become an even more difficult, long and traumatizing process (Program for Torture Victims, 2009). In order to gain asylum one must file a Form I-589, Application for Asylum and for Withholding of Removal within a year of arriving to the U.S., interview with a Department of Homeland Security (DHS) Los Angeles Asylum Officer who can grant you asylum or Notice to Appear is issued and the case is referred to a Federal Immigration Judge (IJ) (U.S. Citizenship & Immigration Services, 2009). If an asylum case is sent to the Los Angeles Federal Immigration Court most asylum seekers are assigned an attorney, who then refers clients to PTV. The medical and clinical team conducts forensic assessments, writes affidavits for asylum interviews with DHS Asylum officers and immigration court proceedings, and serves as expert witnesses in immigration court as needed. PTV aims to ensure that asylum-seekers do not continue to fall through the cracks in policies, social services (Sakamoto, 2007) and do not have to continue to fight the risks of homelessness, hunger and health (mental and physical health) problems (Jones, 2001; Lacroix, 2006; Program for Torture Victims, 2009). The staff at PTV is trained to provide services that aim at decreasing the risk of these social and health problems. A majority of staff members have been with the agency for 6 or more years, but bring with them many years of knowledge and experience working with torture survivors. The treatment team consists of two physicians (internal medicine

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and gynecologist), two clinical psychologists, two therapists, one MFT, one MSW, case management and a team of interpreters. The PTV clinical staff and team of interpreters speak the following languages: Amharic, Arabic, Armenian, Farsi, Punjabi, Russian, Tigrinya and Urdu. The interpreters are used for cultural consultation, but they are not experts in every dialect of their language nor have they shared the same cultural experiences as the clients. Case management assists clients integrate into Southern California’s society and culture (Program for Torture Victims, 2009). According to social work literature more attention is needed in the integration of immigrant, refugee and asylum-seeking populations into the host society (Balgopal, 2000; Lacroix, 2006; Nash et al., 2006). It is important to note integration as a strength at PTV, while continuing to promote that effort is made by PTV staff to establish culturally appropriate integration and intervention principles. The medical and clinical staff members (therapists, interpreters, and case manager) are sensitive to the clients through utilizing principles of trauma theory and working crossculturally to ease any hesitation or unfamiliarity clients may have to the Western practice of medicine and therapy services (American Psychology Association, 2003; Kinzie, 2001; Briere & Scott, 2006). More than three fourths of the world’s population lives in non-Western cultures and 90% are unfamiliar with Western psychotherapeutic constructions (Berthold & Durocher, 2003). PTV clinicians explained their approach as using the person in environment (Zastrow & Kirst-Ashman, 2007; Greene, 1999), cross-cultural principles, and culturally appropriate interventions that can look radically different for each client depending on the therapeutic relationship and the way the therapist implements these principles (M. Berthold, personal communication, October 7, 2009). For this reason, additional training is essential to PTV’s clinical staff members in order to ensure that clinicians are continuing to learn from one another and share information about interventions, therapeutic relationships and cultural

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practices. The following section will identify a model for implementing a cross-cultural skills building training program for PTV clinical staff.
LOGIC MODEL

A logic model is a useful framework for examining outcomes (United Way, 1996). A logic model includes identifying inputs, activities, and outputs or outcomes to be achieved. Based on the logic model for the proposed cross-cultural skills building training (Appendix A), the input for the training program is PTV clinical staff will incorporate the cross-cultural skills building training into their clinical staff meetings. Clinical staff meetings occur every Thursday of the month. The training program will build on the current training curriculum (Building Cross-Cultural Clinical Skills in Providing Mental Health Services to Refugee Survivors of Torture, Berthold & Durocher, 2007) and other agency training materials. For the purposes of this training program, the activities will including incorporating the cross cultural skills training once a month, on the last Thursday of the month, into the clinical staff meetings. The format for the training program is that each month one member of the 6 person clinical staff will be identified to present at the staff meeting on the last Thursday of the month. There will be 6 trainings in total, over 6 months. The clinical staff member selected to present will prepare a 30-minute presentation on particular variations in clients’ customs, backgrounds, clinical approaches and personal experiences. These presentations should include case vignettes or handouts on the material being presented. Then, the second activity is to have tangible learning devices so that a resource guide can be created, compiling all the handouts or case vignettes from the presentations. The resource guide is meant to be useful for agency staff members as well as a resource for future community trainings. The third activity is to create a form for case management to complete at intake. The form would be in addition to all other intake materials and would contain questions that are more culturally competent. These questions would be drawn from Kleinman’s Questions

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(1978). The purpose of creating and adding this form to the intake packet is to elicit clients’ beliefs about illnesses in a respectful and culturally competent manner (Pilcher et al., 2008). The fourth activity is to translate agency forms. Translating agency forms is essential in building cultural competency because it ensures that clients are able to read and understand the materials they are signing. Likewise, clients with limited English proficiency “have difficulty entering, continuing and benefiting from services” (Sue et al., 2009, p. 534). The final activity includes monitoring data collected from the Client Outcome Study (PTV research project). The activity will be to monitor clients’ responses, at one-year follow up, on what worked and what did not work with the services as well as attitudes and behaviors of PTV clinical staff. The follow-up interview will be a self-report by clients’ and will include questions on the client’s perception of cultural competency within PTV staff and services. The output from the training will be an established cross-cultural skills building program that includes translated agency materials, a new form at intake, and 6 sessions of training that produce resources (case vignettes, information on clinical approaches, and presentation handouts) for an agency resource guide. Finally, the outcomes of the training program are broken into initial, intermediate, and long-term outcomes. The initial outcome is to increase the PTV clinical staff’s knowledge of cultural diversity measured through a Self-Assessment Checklist (Goode, 2004). The intermediate outcome is that PTV staff are more confident to use the knowledge from the training to interact with clients outside of their clinical expertise measured through the Clinical Cultural Competency Questionnaire (Like, 2001). The long-term outcomes are to improve client functioning as measured through self-report in the one-year follow-up interview and integration of specialized cultural competency training measured by staff being able to train others.

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RESEARCH QUESTIONS This program evaluation will test four research questions to address all of the outcomes in the logic model. The four research questions include:
Research Question 1:

What will PTV clinical staff gain from the cross-cultural skills building training?
Research Question 2:

How does the training impact PTV clinical staff members’ ability to interact with clients in the clinical setting?
Research Question 3:

What impact will the training have on client functioning?
Research Question 4:

What new information will PTV staff be able to integrate into the existing community cross-cultural skills building training?
RESEARCH DESIGN

Because the demographic population at PTV is constantly changing, it is important that PTV staff are continuously learning about cultural customs, background, client traditions and practices (religious, cultural, communal). The goal of this training program is to provide cross-cultural skills building training to PTV clinical staff (6) who participate in weekly staff meetings to help these clinicians become more aware of cultural differences and how these differences may impact their professional practice. In order to achieve the goal of this program, the objectives are to increase PTV clinical staff knowledge of cultural diversity and differences and increase client functioning.

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SAMPLING STRATEGY The study will focus on 6 PTV clinical staff participating in the training program as well as clients who participate in the intake process for PTV services during the 6-month training program. The sample of 6 PTV clinical staff members will include one case manager, one physician, and four psychologists/therapists. The sample of clients will include those participating in the intake process for PTV services during the 6-month training program in order to track the level of services clinicians provide after receiving the training until oneyear follow up. Not all clients who participate in the intake process continue to receive services from PTV, but it is important to track those that answered Kleinman’s Questions to evaluate whether or not the questions are perceived as more/less culturally appropriate than the previous “Western-framed” intake questions. Since neither the staff nor the clients will be recruited for the program, recruitment time will not be needed. INFORMED CONSENT AND ANONYMITY Since the program being evaluated is for training purposes an informed consent will be given to PTV staff members at the beginning of the training program to ensure that each staff member agrees to participate and is not being forced to participate because it takes place during their weekly meeting. In the informed consent form it will explain that all the information gathered from self-assessments and evaluation questionnaires will be anonymous. To ensure anonymity each staff member will be given a number and the only person that will know this information will be the Principal Investigator (Lorene Gingerich). The instruments will be kept in a secure location in PTV’s office. Since the findings of this study are for the benefit of the agency and not for publishing purposes, the information will only be shared with PTV administrators and PTV staff members. However, for the purposes of the one-year follow-up interview, there is an existing participant consent form that is explained and administered at intake. Therefore, all the clients that are of interest to this study (those participating in the intake process during the 6-months of training) will have already completed the informed consent at

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intake. Also at intake clients are given a client number that is used to label their file and on every sheet that put into their client file. Therefore, the Client Outcome Study is anonymous and no PTV staff will know the clients identity (except the two staff members assisting with the study). During the one year follow-up interview clients will be asked questions about their satisfaction with PTV services and clinicians’ knowledge regarding cultural practices or norms. This information will be collected and reviewed by a PTV non-staff member (MSW intern) in order to ensure client confidentiality and prevent any conflicts between clinicians and client. Also, because the interviews will take place one year following intake, the participants will be asked to provide contact information (phone or email address) so that the researchers can contact the participants for the follow-up interview. No other information that may identify the individual’s identity will be collected during the research study. ANALYSIS PLAN Data collection will consist of the intake form with Kleinman’s Questions, one initial posttraining self-assessment by clinical staff, an intermediate questionnaire, one long-term post-training interview of clients to assess staff knowledge and confidence and client functioning, and the other long-term data collection will measure the ability of staff to train others. The first cultural competency building technique will take place in the intake process. The intake process consists of the case manager collecting information about demographics and the presenting problem as well as consent to services. The primary complaint/presenting problem tool is based on Western practice of medicine and therapy (American Psychology Association, 2003; Kinzie, 2001; Briere & Scott, 2006). Therefore, research suggests integrating Kleinman’s Questions into health and social services to elicit clients’ beliefs about illnesses in a respectful and culturally competent manner (Pilcher et al., 2008). Following the cross-cultural skills building training of PTV clinical staff there will be an

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initial post-training self-assessment administered to clinical staff. The self-assessment tool will be administered (in paper form) one week after the sixth presentation in the Thursday clinical staff meeting. The clinicians will be given one week to complete the self-assessment, which will be collected in the following week’s staff meeting. The selfassessment tool will be a modified version of Goode’s (2004) Self Assessment Checklist. The Self Assessment Checklist asks statements about physical environment, materials and resources, communication styles and values and attitudes. This tool will measure how or if the training increased the PTV clinical staff’s knowledge of cultural diversity in these areas. The intermediate questionnaire will be administered 3 months after the training to assess if PTV staff are more confident in using the knowledge from the training to interact with clients outside of their clinical expertise. The self-assessment tool will be the Clinical Cultural Competency Questionnaire modeled after the Like (2001) instrument. The questionnaire will be in a Likert format and will measure the knowledge clinicians gained from the training and the confidence and ability to use their knowledge in practice. The questionnaires will also be administered in the clinical staff meeting 3 months posttraining. There is little concern for staff turnover since PTV’s clinical staff members have been with the agency for nearly 11 years (with the exception of the case manager who has been with the agency for 6 years). Like the initial self-assessment tool the clinicians will be given one week to complete the questionnaire and it will be collected in the following week’s staff meeting. The long-term outcome is to assess client functioning at the one-year follow up interview measured by self-report. The data will be collected in coordination with PTV’s existing Client Outcome Study where clients who participated in the intake process for PTV services have already consented for the interview. The goal will be to target individuals who participated in the intake process during the 6-month training program to track the level of services clinicians provide after receiving the training. As mentioned above, not

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all clients who participate in the intake process continue to receive services from PTV, but it will be important to follow-up with clients to evaluate whether or not Kleinman’s Questions are perceived as more or less culturally appropriate than the previous “Western framed” intake questions. Currently in Part III of the Client Outcome Study there are eight open-ended questions about clients’ experiences with PTV services, including case management, therapy and medical services. Then, questions will be included regarding client satisfaction with PTV cultural competency services (translated materials and interpreters) and clinicians’ knowledge regarding cultural practices or norms. The data will be analyzed by identifying themes from the information clients provide. The themes this study will be interested in are clients identifying their experience with services, specifically if services were delivered in a way that the client liked or was familiar with or if the client identifies any areas of discomfort or challenges. Finally, staff being able to train others will measure the integration of the cross-cultural skills building training. This outcome does not have an established measure, therefore it will be evaluated after the next community training. The basis of the evaluation will be assessing whether or not PTV was able to integrate case vignettes or handouts, practices, skills and knowledge learned from the in-house cross-cultural skills building training.
RELEVANCE TO SOCIAL WORK MACRO PRACTICE

The relevance of this study to the agency is that it provides a way for the clinical staff to use the current training they provide out in the community and use the curriculum in-house to build a deeper understanding and knowledge about cultural backgrounds outside of their clinical expertise. Since most of the clinical staff is part-time many do not come in contact with other clinicians’ clients. Although PTV clinical staff strive to provide culturally appropriate interventions to their clients, they do not have knowledge and awareness of all cultural factors that may arise in the clinical setting. Therefore, this study is relevant to PTV because it provides a mechanism for staff to expand their knowledge for the benefit of the clients.

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The program is also relevant to the community because the long-term outcome is to provide more culturally competent training to professionals in the community, with additional examples and practices tips (case vignettes and personal experience). The program will help professionals in the community become more aware of cultural differences and how these differences may impact their professional practice. The limitations to this study will be ensuring that clinical staff members attend the meeting and are prepared to present. Getting buy-in from staff will not be difficult. However, clinicians often have client emergencies or get called to court on days when there are staff meetings. So one limitation will be coordinating availability amongst the clinical staff members. Likewise, if a staff member misses a meeting/presentation it may skew the self-assessment and evaluation of knowledge attained from the program. The second limitation to the study is tracking clients for the one-year follow-up interview. The MSW research assistant currently conducting Year 10 of the Client Outcome Study struggles with contacting and scheduling clients for interviews. Additionally, this study will include all clients who completed the intake process for the 6-months during the training program. It may be particularly difficult to track clients who may not have returned after intake to receive services. Similarly, the population PTV serves is difficult to track given that most do not have legal status.
FEEDBACK ON PROGRAM EVALUATION

Dr. Quiroga is one of the founders of PTV and provides in-house medical care. Dr. Quiroga as the only medical team member at the agency and provides medical care to all PTC clients (if needed). Dr. Quiroga works with the case manager, clinicians and translators to provide the best care for his clients. In speaking to Dr. Quiroga, he expressed the need for more translators and more translated medical information. Because medicine is practiced and perceived differently in every culture, Dr. Quiroga was involved with giving feedback and input in this program evaluation. Likewise, Dr. Quiroga is often the representative that goes to the Department of Homeland

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Security, LAFLA and Public Counsel to give trainings. Therefore, he was receptive to integrating more case examples and additional information from other clinicians into the training curriculum. Another, key informant was Dr. Megan Berthold the Director of Research and part-time therapist (LCSW) at PTV. Dr. Berthold is one of the clinicians that created the most recent and comprehensive training at PTV called “Building Cross-Cultural Clinical Skills in Providing Mental Health Services to Refugee Survivors of Torture” (Berthold & Durocher, 2007). Dr. Berthold was actively involved in the research (on torture and cross cultural training) and evaluation of this study’s training program for PTV. Dr. Berthold is also the Principal Investigator (PI) for the ongoing Client Outcome Study at PTV. Therefore, Dr. Berthold gave her opinion on the feasibility of adding questions about client satisfaction with PTV’s cultural competency services (translated materials and interpreters) and clinicians’ knowledge regarding cultural practices or norms. In fact, Dr. Berthold expressed interest in incorporating knowledge found in this study into the PTV research study and training curriculum. Finally, Dr. Jene Moio is a MSW and pro bono research analyst from UCLA, who has been working with the agency for over 6 years. Dr. Moio began her work with PTV as a part of her dissertation. Through her work at PTV Dr. Moio has become an expert in the effects of torture on women. Dr. Moio was a key informant to the issue of cultural competency because she was available for consultation on her findings about women and different cultural experiences.
AGENCY EXPERIENCES WITH RESEARCH EXERCISE

During meetings (beginning in September), clinical staff expressed a need for more organized information sharing. This program was a direct response to this need. After building this program model, meetings were conducted with agency staff about implementing a cultural-competency training program. The clinical staff and

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administration were very supportive of the concept. Then, the design of this study could work effectively at PTV because the program would be built into existing staff meetings and agency evaluation methods. Although the clinicians will be asked to prepare a presentation and complete two self-assessments, there is a general sense of buy-in and enthusiasm about the program. As mentioned above, PTV staff members have been with the agency for a very long time and encourage continuous learning.

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APPENDIX A

PROGRAM LOGIC MODEL

Program: Cross-Cultural Skills Building: To provide integrated cross-cultural skills building training during monthly PTV staff meetings.

INPUT Agency clinical staff has monthly (6 total) cross-cultural skills building training sessions: current training curriculum and other training materials.

ACTIVITIES One clinical staff presents monthly for 30 minutes on variations in clients’ customs, background, clinical approaches that worked and did not work, personal experiences, case studies or compiled vignettes. Resource guide: compile handouts or case vignettes from presentations and potentially use for community training. Create form for case manager and clinicians (with Kleinman’s Questions) and add forms in resource guide. Translate agency forms During Client Outcome study (agency research project) interview clients during 1-year follow-up on what worked and what did not work, including Kleinman’s Questions and self-report by clients.

Training program: including 6 sessions, resource guide, resources (case vignettes, new clinical approaches form, presentation handouts) available.

OUTCOMES INITIAL Increase clinical staff’s knowledge of cultural diversity measured through self-assessment (Goode, 2004). INTERMEDIATE Staff are more confident in using knowledge and interacting with clients outside of their clinical expertise. LONG-TERM Improve client functioning as measured by self-report in 1-year follow-up interview Integration of specialized cross-cultural skills training measured by PTV staff being able to train other community members.

a a
OUTPUT

a

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REFERENCES Alvarez, A. N. & Chen, G. A. (2008). Ruth as an Asian American: A multicultural, integrative perspective. In Case approach to counseling and psychotherapy (G. Corey, Ed.). Belmont, CA: Wadsworth. American Psychological Association. (2003). Guidelines on multicultural education, training, research, practice and organizational change for psychologists. American
Psychological Association, 58(5), 377-402.

Amnesty International. (1975). Report on torture. First American ed. Amnesty International, 1973. Amnesty International. (1994). Ethical codes and declarations relevant to the health
professions: An Amnesty International compilation of selected ethical texts. Third ed. Amnesty International.

Amnesty International. (2000). Report 2000. Baltimore: Lucas. Balgopal, P. R. (2000). Social work practice with immigrants and refugees. New York: Columbia University Press. Berthold, S. M. & Durocher, R. M. (Eds.). (2003). Proceedings from PTV Training ‘03: Building
cross-cultural clinical skills in providing mental health services to refugee survivors of trauma. Los Angeles, CA.

Briere, J. & Scott, C. (2006). Principles of trauma therapy: A guide of symptoms, evaluation,
and treatment. Thousand Oaks, CA: Sage Publications.

California Department of State Office of Admissions Refugee Processing Center (2009). Bureau of Population, Refugees, and Migration: Summary of refugee admissions as of September 30, 2009. Retrieved October 5, 2009 from www.wrapsnet.org/ LinkClick.aspx? Dyche, L. & Zayas, L. H. (2001). Cross-cultural empathy and training the contemporary psychotherapist. Clinical Social Work Journal, 29(3), 245-270. Fabri, M. R. (2001). Reconstructing safety: Adjustments to the therapeutic frame in the treatment of survivors of political torture. Professional Psychology: Research and Practice,
32(5), 452-457.

115

Falicov, C. (1995). Training to think culturally: A multidimensional comparative framework.
Family Process, 34, 373-388.

Goode, T. D., (2004). Promoting cultural competence and cultural diversity for personnel
providing services and supports to children with special health care needs and their families. Retrieved from Georgetown University National Center for Cultural

Competence www11.georgetown.edu/research/. Greene, R. (1999). Ecological perspective: An eclectic theoretical framework for social work practice. In Human behavior theory and social work practice (2nd Ed.), 259-308. New York: Aldine De Gruyyer. Gutierrez, L., Fredricken, K., & Soifer, S. (1999). Perspectives of social work faculty on diversity and societal oppression content: Results from a national survey. Journal of
Social Work Education, 35(3), 409-419.

Healy, L. M. (2008). Social work as a force for humane global change and development. In International social work: Professional action in an independent world (2nd Ed.), 257-271. New York: Oxford University Press. Jones, A. (2001). Child asylum seekers and refugees: Rights and responsibilities. Journal of
Social Work, 1(3), 253-271.

Kinzie, J.D. (2001). Psychotherapy for massively traumatized refugees: The therapist variable.
American Journal of Psychotherapy, 55, 474-490.

Kleinman, A., Eisenberg, L., Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Ann Intern Med, 88(2), 251-258. Lacroix, M. (2006). Social work with asylum seekers in Canada: The case for social justice.
International Social Work, 49(1), 19-28.

Like, R. C. (2001). Clinical cultural competency questionnaire (Post-training version). The Center for Healthy Families and Cultural Diversity. Retrieved from www2.umdnj. edu/fmedweb/ chfcd/Cultural_competency_questionnaire_post-training.pdf Lo, H. T. & Fung, K. P. (2003). Culturally competent psychotherapy. Canada Journal of
Psychiatry, 48(3), 161-170.

116

Lopez, S. (2006, February 19). Years are lost, but a family’s hope lives. Los Angeles Times. Los Angeles County Census (2000). Foreign born population - origins, citizenship & year of
entry. Los Angeles, CA: Los Angeles County Census.

Manning, R. D. (1995). Multiculturalism in the United States: Clashing concepts, changing demographics and competing cultures. International Journal of Group Tensions,
25(2), 117-168.

Matthews, L. (2002). Coping in the aftermath of the World Trade Center tragedy: An immigrant perspective. Journal of Immigrant and Refugee Services, 1(2), 101-108. Nash, M., Wong, J. & Trlin, A. (2006). Civic and social integration: A new field of social work practice with immigrants, refugees and asylum seekers. International Social Work,
45(4), 345-363.

Office of the United Nations High Commission for Human Rights. (2007). Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, entry into force 26 June 1987. Retrieved from www2.ohchr.org/ english/law/cat.htm. Pilcher, E. S., Charles, L. T., Lancaster, C. J. (2008). Development and assessment of cultural competency curriculum. Journal of Dentist Education, 72(9), 1020-1028. Program for Torture Victims. (n.d.). Our mission, our story, healing the body and mind, legal
representation for torture survivors, and will you help? [brochure]. Los Angeles,

CA: Author. Program for Torture Victims: Client services training and research. (2009). Los Angeles, CA. Quiroga, J. & Jaranson, J. (2005). Politically-motivated torture and its survivors: A desk study review of the literature. [Thematic Issue] Torture, 2-3, 1-111. Sue, D. W. & Torino, G. C. (2005). Racial-cultural competence: Awareness, knowledge, and skills. In R.T. Carter (Ed.) Handbook of radical-cultural psychology and
counseling: Training, and practice. (Vol. 2), pp. 3-18. Hoboken, NJ: Wiley.

Sue, S. (1998). In search of cultural competence in psychotherapy and counseling. American
Psychology, 53, 440-448.

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Sue, S., Zane, N., Hall, G. C. N., Berger, L. K. (2009). The case for cultural competency in psychotherapeutic interventions. Annual Review of Psychology, 60, 525-548. United Way of America. (1996). Measuring program outcomes: A practical approach. Alexandria, VA: United Way Press. U.S. Citizenship & Immigration Services. (2009). Refugee & asylum: Asylum. Retrieved on from www.uscis.gov/portal/site/uscis/menuitem.eb1d4c2a3e5b9ac89243c6a7 543f6d1 a/?vgnextid=f39d3e4d77d73210VgnVCM100000082ca60aRCRD&vgnextchannel=f39 d3e4d77d73210VgnVCM100000082ca60aRCRD. U.S. Department of Health & Human Services, Department of Families & Children, Office of Refugee Resettlement. (2009). Services for survivors of torture. Retrieved from www.acf.hhs.gov/programs/orr/programs/services_ survivors_ torture. htm. U.S. Department of State, U.S. Department of Homeland Security, & U.S. Department of Health and Human Services. (2009). Proposed refugee admission for fiscal year
2009: Report to Congress. Retrieved from www.state.gov/documents/

organization/113507.pdf Whaley, A. & Davis, K. (2007). Cultural competence and evidence-based practice in mental health services: A complementary perspective. American Psychology, 62, 563-574. Zastrow, C. & Kirst-Ashman, K. K. (2007). Theoretical perspectives on human behavior and the social environment. In Understanding human behavior and the social
environment (7th Ed.) p. 1-41. Belmont, CA: Thompson Higher Education.

Successful Aging and Its Implications for Chinese Communities
SARAH JACOBUS
Directed Research in Social Work Professor Iris Chi

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Ideas about what constitutes a positive experience of old age can be traced back to a treatise by the Roman philosopher Cicero, who maintained that later life could be a period of great vitality and engagement (Baltes & Baltes, 1990). Until the last few decades, however, the prevailing Western theoretical paradigm depicted the aging process in terms of physical decline and social withdrawal. In a departure from this gloomy representation, social gerontologists have begun to redefine what it means to grow old, conceptualizing old age as a stage of life in which good health, psychological growth and contributions to society are active possibilities (Holstein & Minkler, 2003; Minkler & Fadem, 2002; Rowe & Kahn, 1997). The concept of successful aging, as this collection of theories and definitions is most commonly known, is informed by the notion of “adding life to years, not merely years to life” (Minkler & Fadem, 2002, p. 229). Approaches to successful aging vary. Some are outcome-oriented, focused on a minimal decrease in physical functioning, sustaining the physical and psychological capacities of middle age, and possessing a sense of life satisfaction and well-being (Havighurst, 1961). The notion of remaining productive in later life, whether by paid or unpaid services and contributions, falls within this category of outcomes of successful aging (Bass & Caro, 2001). The work of German psychologists Baltes and Baltes (1993) explores psychological resources inherent in successful aging. Their concept of selective optimization and compensation emphasizes effective adaptation to age limitations and sustaining a sense of self-efficacy by adjusting goals to match actual capacities, or doing the best with what you have. In the late 80s, under the auspices of the MacArthur Foundation Study of Successful Aging, John Rowe and Robert Kahn began formulating what has become the leading theoretical paradigm in gerontology and geriatrics and the most widely used concept in biomedical research (Holstein & Minkler, 2003). Rowe and Kahn posited that much of what researchers had traditionally viewed as effects of aging were in fact effects of disease, maintaining that certain functional decreases were the result of external factors

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such as diet and exercise and not necessarily age-determined. They drew a distinction between “usual” aging, experiencing the normal physical, social and cognitive losses of aging, and “successful” aging. It was possible, they argued, to reach old age free of disease, functional decline and cognitive loss (Holstein & Minkler, 2003; Hooyman & Kiyak, 2008; Knight & Ricciardelli, 2003; Minkler & Fadem, 2002; Phelan, Anderson, LaCroix, & Larson, 2004; Rowe & Kahn, 1987, 1997) . Rowe and Kahn expanded their definition in a 1997 article and their mass-market book Successful Aging the following year to encompass a multi-dimensional framework with three major components: a low probability of disease and disease and disease-related disability, high cognitive functioning, and active social engagement. Their model stresses the importance of individual lifestyle choices—such as proper nutrition, physical exercise, and community involvement through volunteer activities—that promote health, prevent disease and foster continued involvement in social networks (Holstein & Minkler, 2003; Hooyman & Kiyak, 2008; Rowe & Kahn, 1997). A positive vision of old age, to be sure, but how realistic are these criteria for the majority of older adults? In one of few studies of successful aging in China, a sample of Shanghai adults, age 65 and older, completed the Shanghai Successful Aging Project Questionnaire. Using a three-pronged definition of successful aging that closely paralleled Rowe and Kahn’s, the study sought to compare rates of successful aging in Shanghai with those found in Western studies. The project used international measurement instruments to facilitate the comparison. Results of the Shanghai study showed less than half, 46.2%, of the participants overall who met the three Rowe and Kahn criteria for successful aging. The percentage may sound low, but the results are similar to research findings from the West (Li, Wu, Zhang, Xue, He, Xiao, Jeste & Zhang, 2006). In fact, a study from Alameda County, California, a major urban area that includes the cities of Berkeley and Oakland, found only 18.8% of respondents ages 65 to 99 to be aging

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successfully according to Rowe and Kahn. However, 50.3% of these same individuals rated themselves as aging successfully. 36.8% of the participants classified as aging successfully by Rowe and Kahn’s standards did not rate themselves as aging successfully. Inversely, out of the participants classified as not aging successfully, 47.3% believed that they were (Strawbridge, Wallhagen, & Cohen, 2006)! This disparity between older adults’ perceptions of their own aging process and researchers’ definitions underscores one of the most frequent criticisms of Rowe and Kahn’s theoretical framework: that it fails to recognize the impact of a diverse range of experiences, values and cultural orientations on the meaning of aging well (Holstein & Minkler, 2003; Hooyman & Kiyak, 2008; Knight & Ricciardelli, 2003; Torres, 2003). Critics argue that there is no universal idea of what constitutes success, or even good health (Torres). Standards vary by age group and even between individuals. Portraying healthy aging mainly in terms of physical function and absence of disease provides a limited picture, excluding the concept of well-being (Strawbridge et al., 2006). In a study of China’s “oldest old,” for example, 60% of respondents in their 80s describe themselves as being in “good health,” despite chronic conditions and functional limitations (Wu & Schimmele, 2006). By making successful aging a matter of individual choices and behaviors, Rowe and Kahn disregard socioeconomic and environmental factors that limit elders’ access to the tools of self-care. For instance, a daily regimen of physical exercise and the expense of organic veggies is likely to be out of the realm of possibility for a 65-year old woman who cannot yet afford to retire and comes home from work after dark to an unsafe neighborhood (Cardona, 2008; Holstein & Minkler, 2003; Hooyman & Kiyak, 2008; Liang, Liu, & Gu, 2001; Minkler & Fadem, 2002). Making individuals primarily accountable for maintaining health also absolves the government of its responsibility to provide health and social welfare resources at a time when programs are jeopardized by funding cutbacks and the economic downturn (Cardona; Scannell, 2006).

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Critics charge that this framework presumes that successful coping in later life requires sustaining youthfulness, postponing the characteristics of normal aging. A measure of health maintenance, then, becomes the capacity to retain a youthful, or middle-aged, appearance (Cardona, 2008; Holstein & Minkler, 2003; Hooyman & Kiyak, 2008). Another analysis contends that by resorting to the either/or language of successful and unsuccessful, the inability to adhere to the successful aging model implies personal failure, thus further devaluing those who are already marginalized in society, including older women and racial minorities. A physical impairment or disability also makes an older adult ineligible for successful aging status, according to Rowe and Kahn (Holstein & Minkler, 2003; Minkler & Fadem, 2002). But would we really think of renowned physicist Stephen Hawking, who suffers from ALS—Lou Gehrig’s disease—or violinist Itzhak Perlman, taking the stage in a wheelchair, as failing the test of successful aging? Perhaps most important for consideration in the context of Chinese communities is the claim that Rowe and Kahn’s successful aging model is culture-specific, shaped by values that are not only Western, but distinctly American in character. The very language of this paradigm reflects a competitive society that prizes external appearances of success and values individual achievements and initiative (Holstein & Minkler, 2003; Torres, 1999). For older adults in this culture, success is measured by degrees of self-sufficiency and independence, how well they can function on their own. One California geriatrician goes so far as to assert, not completely in jest, that dependence and being a “burden” on others is so great an affront to the national mythology celebrating personal freedom and autonomy as to be “un-American” (Scannell, p. 1416)! For Chinese elders, the concept of self-sufficiency is something of a mystery. Why would anyone with a family willing to meet their needs want to be self-sufficient in old age (Torres, 2002)? Even in the face of modernization and rising Western influence in China, the importance of the group continues to take precedence over that of the individual. This emphasis on the collective is especially prevalent among the current generation of Chinese elders,

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most of whom came of age in the 40s and 50s. In keeping with the traditional cultural value of social harmony, Chinese elders tend to be more concerned with how they are viewed by others, setting greater store by being tolerant and agreeable. Contribution to group well-being is a measure of individual self-worth (Mjelde-Mossey & Chi, 2005; Torres, 1999, 2002; Wu, Yue, Silverstein, Axelrod, Shou, & Song, 2005). In individualistic American culture, on the other hand, elders think of successful aging in terms of their personal outlook on the world, stressing optimism, motivation and enthusiasm (Cardona, 2008; Torres). Rowe and Kahn’s emphasis on productive activities in later life strongly reflects mainstream Western culture. Chinese culture affords permission for elders to slow down and take a more contemplative view of life, freed from the pressures of productive labor (Hooyman & Kiyak, 2008). The family remains the primary unit of social and economic support for elders in China. The concept of filial piety, reinforced by law requiring adult children to support and assist their parents, tends to carry more symbolic than actual importance for the younger generation of Chinese, especially in urban areas. The easing of official policies regarding family responsibility for elder care has made placing elders in homes for the aged more socially acceptable in China’s large cities. Still, the expectation that children will care for aging parents persists in Chinese society (Joseph & Phillips, 1999; Leung, 2001; Yi, 2007). A majority of older adults receive regular financial assistance from their adult children, the inverse of the pattern in the U.S., where not only cultural values but public policy as well promote greater independence from family support among elders (Wu et al., 2005). The traditional three-generation extended family household may be giving way to a more diverse range of living arrangements in both rural and urban China, spurred by a migrating labor force, reduced fertility rates and modernization. But the proportion of Chinese elders who live with their children remains considerably higher than in the West (Silverstein, Cong, & Li, 2006). Western culture prioritizes living independently as long as

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possible and tends to equate dependence with lack of dignity (Scannell, 2006). However, research shows that for Chinese elders who adhere to more traditional values, living with adult children creates a greater sense of life satisfaction and purpose and is an important reflection of successful aging (Silverstein et al., 2006). For adult children as well, parents in co-residence are more likely to be seen as a resource than a burden, providing assistance with childcare and household chores (Leung, 2001). Studies reveal other differences in cultural-value orientation that raise questions about the suitability of the successful aging framework for Chinese elders. Rowe and Kahn’s model places heavy emphasis on volunteer activities in the community as a condition for successful aging. This concept is comfortably aligned with Western culture, where diverse social networks of family, friends, neighbors and organizations are normative. For Chinese elders, social activity is overwhelmingly centered around home and family. Group participation, even social interaction, outside the family structure is an unfamiliar practice (Cheng, Lee, Chan, Leung, & Lee, 2009; Wu et al., 2005). Even in urban Hong Kong, a movement among policymakers to encourage elders to engage in volunteer activities has been slow to catch on (Mjelde-Mossey & Chi, 2005). China’s tradition of respect for elders has perhaps been eroded by the rapidly changing economy and social structure. Yet Chinese reverence for elders’ knowledge and wisdom still stands in sharp contrast to the negative attitudes and discrimination toward older adults of American society (Wu et al., 2005). Aging in the West is cause for anxiety, managed by the attempt to forestall the inevitable declines, and even physical appearance, of aging (Andrews, 1999; Cardona, 2008; Holstein & Minkler, 2003). Mass marketing in the U.S. proclaims that “80 is the new 60!” and “Today’s old is tomorrow’s young!” (Scannell, 2006, p. 1416) In Chinese culture, old age is not a stage of life to be feared or avoided, but it is accepted with all of its challenges (Torres, 2003).

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REFERENCES Andrews, M. (1999). The seductiveness of agelessness. Aging and Society, 19, 301-318. Baltes, P.B. & Baltes, M.M. (1990). Psychological perspectives on successful aging: The model of selective optimization with compensation. In P.B. Baltes & M.M. Baltes (Eds.)
Successful aging: Perspectives from the behavioral sciences (pp.1-34).

New York: Cambridge University Press. Bass, S. & Caro, F. (2001). Productive aging: A conceptual framework. In N. Morrow-Howell, J. Hinterlong, & M. Sherraden (Eds.) Productive aging: Concepts and challenges (pp. 37-77). Baltimore: Johns Hopkins University Press. Bowling, A. (2007). Aspirations for older age in the 21st century: What is successful aging?
International Journal of Aging and Human Development, 64(3), 263-297.

Cardona, B. (2008). ‘Healthy ageing’ policies and anti-ageing ideologies and practices: On the exercise of responsibility. Medicine, Health Care and Philosophy, 11, 475-483. Cheng, S., Lee, C., Chan, A., Leung, E., & Lee, J. (2009). Social network types and subjective wellbeing in Chinese older adults. Journal of Gerontology: Psychological Sciences,
64B(6), 713-722.

Havighurst, R.J. (1961). Successful aging. The Gerontologist, 1(1), 8-13. Holstein, M. & Minkler, M. (2003). Self, society, and the “new gerontology.” The Gerontologist,
43(6), 787-796.

Hooyman, N. R. and Kiyak, H.A. (2008). Social gerontology: A multidisciplinary perspective (8th ed.). Boston, MA: Pearson Education, Inc. Joseph, A. & Phillips, D. (1999). Ageing in rural China: Impact of increasing diversity in family and community resources. Journal of Cross-Cultural Gerontology, 14, 153-168. Knight, T. & Ricciardelli, L. (2003). Successful aging: Perceptions of adults aged between 70 and 101 years. International Journal of Aging and Human Development, 56(3), 223-245. Lee, D., Woo, J., & Mackenzie, A. (2002). The cultural context of adjusting to nursing home life: Chinese elders’ perspectives. The Gerontologist, 42(5), 667-675. Leung, J. C. B. (2001). Family support and community-base services in China. In I. Chi, N. L. Chappell & J. E. Lubben (Eds.), Elderly Chinese in Pacific Rim countries (pp. 171-188). Hong Kong, China: Hong Kong University Press.

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Li, C., Wu, W., Jin, H., Zhang, X., Xue, H., He, Y., Xiao, S., Jeste, D., & Zhang, M. (2006). Successful aging in Shanghai, China: Definition, distribution and related factors.
International Psychogeriatrics, 18(3), 551-563.

Liang, J., Liu, X., & Gu, S. (2001). Transitions in functional status among older people in Wuhan, China: Socioeconomic differentials. Journal of Clinical Epidemiology, 54, 1126-1138. Minkler, M. & Fadem, P. (2002). “Successful aging”: A disability perspective. Journal of Disability
Policy Studies, 12(4), 229-235.

Mjelde-Mossey, L. & Chi, I. (2005). Gender differences in expectations predictive of volunteer experience among older Chinese professionals in Hong Kong. Journal of Ethnic and
Cultural Diversity in Social Work, 13(4), 47-64.

Ouwehand, C., de Ridder, D., & Bensing, J. (2007). A review of successful aging models: Proposing proactive coping as an important additional strategy, Clinical Psychology Review, 27, 873-884. Rowe, J. & Kahn, R. (1987). Human aging: Usual and successful. Science, 237, 143-149. Rowe, J. & Kahn, R. (1997). Successful aging. The Gerontologist, 37(4), 433-440. Scannell, K. (2006). An aging un-American. The New England Journal of Medicine,
355, 1415-1417.

Silverstein, M., Cong, Z., & Li, S. (2006). Intergeneration transfers and living arrangements of older people in rural China: Consequences for psychological well-being. Journal of
Gerontology, 61B(5), 256-266.

Strawbridge, W., Wallhagen, M., & Cohen, R. (2005). Successful aging and well-being: Self-rated compared with Rowe and Kahn. The Gerontologist, 6, 727-733. Torres, S. (1999). A culturally relevant theoretical framework for the study of successful aging.
Aging and Society, 19, 33-51.

Torres, S. (2002). Relational values and ideas regarding “successful aging.” Journal of
Comparative Family Studies, 33(3), 417-431.

Torres, S. (2003) A preliminary empirical test of a culturally relevant theoretical framework for the study of successful aging. Journal of Cross-Cultural Gerontology, 18, 79-100.

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Torres, S. (2006). Different ways of understanding the construct of successful aging: Iranian immigrants speak about what aging well means to them. Journal of Cross-Cultural
Gerontology, 21, 1-23.

Wu, B., Yue, Y., Silverstein, N., Axelrod, D., Shou, L., & Song, P. (2005). Are contributory behaviors related to culture? Comparison of the oldest old in the United States and China.
Ageing International, 30(3), 296-323.

Wu, Z. & Schimmele, C. (2006). Psychological disposition and self-reported health among the ‘oldest-old’ in China. Aging & Society, 26, 135-151. Yi, Z. (2007). Dynamics of elderly living arrangements in China. In I.G. Cook & J.L. Powell (Eds.),
New perspectives on China and aging (pp. 93-104). Hauppauge, NY: Nova Science

Publishers, Inc.

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Social Work and the Patient-Centered Medical Home
CAROLINA RODRIGUEZ
Social Policy: Health Care Professor Maryalice Jordan-Marsh

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CASE STUDY

Ms. Betsy Smith, a pseudonym used to protect her anonymity, is a 55-year-old, widowed, retired African-American female, diagnosed with B-cell non-Hodgkin’s lymphoma (NHL) with secondary involvement of the pancreas. Ms. Smith was diagnosed in March of 2006 when she was hospitalized for obstructive jaundice. She has a past medical history of hypothyroidism, hypertension, obstructive jaundice, and congenital blindness. At the time of diagnosis she was living in Cleveland, Ohio. A year after her diagnosis, her husband of 28 years died. A few months after Ms. Smith’s diagnosis, she was treated with chemotherapy at a public community hospital in Cleveland. Her two adult sons and seven grandchildren lived in the same community, where they were born and raised. After three months of treatment with chemotherapy, Ms. Smith developed severe side effects from the chemotherapy agents. She felt this issue was inadequately addressed, possibly because of her race. Distressed and fearful, she consulted with her younger brother living in California. Her brother recommended that she move in with him and his family in order to receive better treatment and care. In 2007, Ms. Smith arrived at the Ontario International Airport to live with her brother, sister-in-law, and two school-aged grandchildren in Victorville, California. According to the U.S. Census Bureau in 2007, Victorville has experienced a population growth of 9.5 percent in recent years. Victorville is north of the San Bernardino Mountains, northeast of Los Angeles, west of Highway 395, and at the edge of the Mojave Desert. Shortly after getting settled, Ms. Smith was referred to a major cancer center approximately 45 miles away. She received chemotherapy treatment for six months, but had to stop treatment due to a weeklong hospitalization for obstructive jaundice. After being discharged from the cancer center, she was told that the cancer center was out of her network, and that therefore she would have to find a new oncologist to treat her

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NHL. In 2009, she came to a major university hospital and found a young oncologist willing to treat her cancer. Ms. Smith travels approximately 89 miles to the clinic for maintenance treatments, which are scheduled once a week for four weeks. The need for treatment will be revisited based on the results of her diagnostic scans.
HEALTH DISPARITIES AMONG MINORITY WOMEN

The issues in this case highlight the disparities that many minority women face when accessing cancer screening and high-quality treatment and follow-up care (Kim et al., 2008). In addition to Ms. Smith experiencing perceived racial- or ethnic-based medical discrimination, she lacks access to a usual source of medical care, such as a primary care physician who could coordinate her care across multiple settings (Crawley, Ahn, & Winkleby, 2008).
HEALTH CARE DISPARITIES AMONG MINORITY WOMEN WITH CANCER

According to a recent longitudinal research study conducted by Penner et al. (2009) on experiences of black patients, subtle and unintentional racial biases of white physicians lead to low utilization of services, feelings of mistrust, and a sense of wariness that affects patient-physician communication. This can contribute to poor adherence to treatment and ultimately poor health outcomes for members of the African-American community. The United States (U.S.) Department of Health and Human Services’ National Healthcare Disparities Report (2007) reported that cancer is the second most common cause of death in the U.S., causing 559,650 deaths in 2007. The report pointed out the cost of cancer was estimated at $206 billion in 2006 with $78 billion in direct costs. In California, the California Cancer Registry, California Department of Public Health, Cancer Facts and Figures report (2009) indicated that over 1,168,500 people have a history of cancer, that about 140,815 will be diagnosed with cancer in 2009, and that 54,600 will die of the disease. At the same time, 89,513 Californians who get cancer in 2009 will survive five years after diagnosis.

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The risk of developing cancer and receiving low quality of care varies by race and ethnicity. African-American women are the most likely to die from cancer even though non-Latina white females are the most likely to be diagnosed with cancer. According to the National Healthcare Disparities Report (2007), African Americans receive a poorer quality of care and have worse access to care than non-Latino whites. In particular, African Americans have worse care when examining patient centeredness, a core component of quality of care, as compared to white non-Latinos. African Americans also suffer from poorer chronic disease management when compared to white non-Latinos.
PUBLIC POLICY FOCUS

This macro-level policy advocacy paper will focus on a public proposal to promote the role of social workers in Patient-Centered Medical Homes (PCMH) by placing this proposal on the policy advocacy agenda of the National Association of Social Workers. This proposal will impact health care consumers—particularly minorities—diagnosed with chronic diseases such as cancer.
AUDIENCE

According to Coffman’s (2007) evaluation approach based on the theory of change expected to occur through advocacy, this policy advocacy affiliation will be with specific constituencies in a public university-affiliated health care system setting. As a second-year master of social work intern at the Simms/Mann University of California, Los Angeles Center (UCLA) for Integrative Oncology, this advocate will inform and educate oncology social workers, medical social workers, and graduate students in the school of social policy.
CONTEXTUAL FACTORS

The passage of comprehensive health care reform is one of the most significant changes undergoing health care in the United States for decades. While the government has not yet adopted or voted on a health care reform plan, the current social and political climate provides opportunities for social workers and nurses to align with U.S. residents as well

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as physicians to improve the quality of health care for all U.S. residents (DeAngelis, 2009). Furthermore, health care professional associations are positioning themselves using issues competition, as outlined by Coffman (2007), in order to propose solutions that advocate for and support patient care in both behavioral models of primary care and in the available funding to support that care (DeAngelis).
INPUTS

PREPARATION AND PLANNING The National Association of Social Workers is promoting the care model for transitions of care for older adults during transitions from one health care delivery system to another (NASW, 2009). A practice update developed by NASW (2009) examined the need for social work interventions during transitions of care and found that psychosocial factors can play a significant role in rehospitalizations of older adults, leading to problematic care transitions. In addition to highlighting the potential benefits of having social workers manage transitions of care in the hospital and/or community, it exemplified the financial impacts and savings that social work interventions can contribute within the medical community and health care delivery systems. Volland, Berkman, Phillips, and Stein (2003) examined the changing role of social workers in health care settings and found five trends that are associated and consistent with a patient-centered medical model. Trend one is the shift to social workers practicing in a multidisciplinary structure. Trend two is the knowledge of social workers of resources regarding navigating health care systems and working with population and/or diseasespecific programs. Trend three is the strong foundation social workers are acquiring on case management and networking. Trend four is the use of evidence-based research to develop effective and therapeutic intervention for consumers and the continuous collection of data for evaluation of patient and systems outcome. Lastly, trend five describes the ability of social workers to design programs, using data to increase the quality of care using cost effective strategies and innovations adopted from national models of care.

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ORGANIZATIONAL CAPACITY BUILDING The Simms/Mann UCLA Center for Integrative Oncology is a national model for providing patient care for individuals and families touched by cancer. Built on a foundation of academic research and advanced treatment approaches, the Center offers educational and support services that integrate psychological, nutritional, spiritual and complementary approaches to healing (personal communication, September 15, 2009). As such, the Center can provide information, knowledge, and wisdom to organize the operational supports this advocate will need to improve cancer care services for minority women (Coffman, 2007).
GOAL SETTING

SMART GOAL To develop a strategic plan for program development, objectives, and activities related to promoting and securing the role of social workers in the Patient-Centered Medical Home. The goal is to present this plan by March 2010 and place it on the agenda of the NASW California Political Action Committee (CALPACE) annual meeting scheduled for May 2010. LANDSCAPE MAPPING Similarly, California Healthline in 2007 reported on a project led by nurses under the direction of physicians to develop innovative, patient-centered personal health information and decision support tools that will promote patient-provider communication and potentially increase patient satisfaction regarding their health care decisions and experiences. The team at the Carol Franc Buck Breast Care Center at the University of California, San Francisco is playing a key role in helping consumers use information technology to better meet their health care needs in an integrated fashion—one of the key tenets of the patient-centered medical home model proposed by physicians. Professional nursing organizations are developing models of care that are patientcentered, efficient, safer, and potentially cost effective. Coffman (2007) suggested that in the preparation and planning phase of advocacy, advocates should engage in

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“Landscape Mapping” in order to assess and collect information to analyze competing options using a value-based criteria (Jansson, 2008). Social workers and nurses can form an alliance to promote their role and participation in a patient-centered medical home in order to increase the quality of care for all consumers, paying special attention to vulnerable populations such as minority women diagnosed with cancer. Robbins and Birmingham (2005) argued that standards of care in care coordination and case management are not profession-specific but rather serve as a standard of practice and a set of guidelines describing the rules, actions, or conditions that direct patient care for providing high-quality care, and in turn for evaluating care. Historically and presently, both nurses and social workers function in the roles of case managers and coordinators employing similar interventions and responsibilities. However, each profession contributes a specific process that is unique and essential to obtaining successful outcomes for consumers and the health care system. Hence, promoting and facilitating professional relationships in a complex and medical-oriented system requires coalition building and bridging alliances to strengthen the image, uniqueness, and practices of both nurses and social workers. SMART GOAL By May 2010, nursing organizations and nurse researchers and leaders from universities and community agencies will be educated and engaged in discussions focused on supporting the collaboration of nurses and social workers in patient-centered medical homes.
METHOD OF DATA COLLECTION

To defend this policy proposal, the social-network analysis method for advocacy evaluation will be utilized for data collection (Dorfman et al., 2009). According to Dorfman, the social-network analysis is an innovative method that explores the connections or relationships that make up the system, examining the relationships among groups using mathematical algorithms.

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ACTIVITIES AND TACTICS MATRIX

Table 1 summarizes activities and tactics for policy and politics and communications and outreach using the Advocacy and Policy Change Composite Logic Model (Coffman, 2007). Rating Scale: 0-10 with “0” being “Not Likely or Low and Negative” and “10” being “Likely or High and Positive.” U.S. politicians are currently exploring ways to finance and sustain a health care reform plan that will provide medical and mental health care to all Americans in a way that will not offset or increase the federal deficit. To do this, infrastructure changes will need to be put in place to ensure that health care will be delivered to medically underserved or vulnerable populations by having a health care workforce that is able to meet the demands of this plan (Sherman, Moscou, & Dang-Vu, 2009). External forces, such as court rulings, flows of revenue, and potential sanctions that health insurance and pharmaceutical companies will impose will drive the enactment of a health care reform plan (Jansson, 2009). On the other hand, internal organizations such as the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Physicians are supporting the patient-centered medical home primary care model of care, based on empirical evidence stating that the ability of medical centers and health professionals to advance societal health and improve patients’ health across the continuum of care will be improved by the utilization of a multidisciplinary team approach to delivery of primary health care (Rosenthal, 2008).
ASSETS AND LIABILITIES AT THE ORGANIZATIONAL LEVEL

The case study presented in this proposal identifies assets and liabilities within the Simms/Mann UCLA Center for Integrative Oncology. According to Jansson (2009), it is sometimes useful to outline assets and liabilities in order to understand the strengths and weaknesses of the organization and system. Assets and strengths are summarized in Table 2 (Jansson, 2009).

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IMPLEMENTATION ISSUES AND PROBLEMS

BENCHMARK: ADVOCACY CAPACITY The National Social Work Association will review and recommend for action the adoption of the role of social workers in patient-centered medical home models. They will also participate in demonstration and pilot projects to demonstrate the quality and effectiveness of social workers working with a multidisciplinary team. BENCHMARK: POLICY The National Social Work Association will increase its constituency base growth by aligning with national and state-wide advocacy coalitions to support the implementation of the role of social workers and nurses in patient-centered medical homes. CHALLENGES TO IMPLEMENTATION One of the main challenges for social workers in gaining visibility and credibility for generating support and a role in patient-centered medical home models will be the lack of a body of knowledge that social workers currently have on this model of care. Based on a literature search for social work and patient-centered medical homes, there were no social work research studies to date or commentaries, issue reports, or briefs written by social workers. The psychology and nursing literature on PCMH promotes the roles of these respective professions in this debate. They are participating in demonstration and pilot projects to provide evidence of the value of using psychologists or nurses to assist primary care providers in building a patient-centered medical home that incorporates and provides patients with the integrated health care they deserve in a comprehensive and compassionate manner (McDaniel & Fogarty, 2009). STRATEGIES TO MINIMIZE PROBLEMS One of the cornerstones on which social work was built is the desire and commitment to

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make a difference for all members of society, especially vulnerable populations. To this end, one means NASW utilizes is advocacy to increase the quality of life of consumers by serving as safety net providers and decreasing health care disparities through the use of policy advocacy, research, coalition building, and maintaining hope (Clark, 2009). In the past, NASW has championed legislation that has changed the quality of life and opportunities for disenfranchised populations such as foster children and families, homeless persons, persistently and mentally ill persons, low-income children and families, and older adults. These successes speak to the capacity and potential social workers employ when they join forces to build support on social issues deemed urgent, critical, and timely. The PCMH model is still evolving today with new additions, developments, and improvements of core principles, based on a patient-beneficial health care system that will ultimately lead to the future reduction or elimination of barriers to care for chronic conditions (Carney et al., 2009). Based upon these ideas and policy proposals, research and policy advocacy around integrating the role of social work and nursing around the development of the PCMH model will promote standards of practice that will ensure that the physical, mental, and social well-being of the underserved patient in a familycentered approach is met.
CONCLUSION

This advocacy proposal presents an opportunity for social workers’ involvement in health care reform and coalition building. Social work can accomplish this by aligning and collaborating with professional nursing organizations to become part of the development of patient-centered approaches to improving the quality of care for consumers and reducing disparities in health care. Ultimately, the perceptions and experiences of consumers about the value of health care for themselves and their family members are one of the primary determinants of utilization. Integrating the role of professional social workers and nurses in the PCMH will empower consumers, especially minority women with cancer, with hope for better health and well-being.

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TABLE 1

ADVOCACY AND POLICY CHANGE COMPOSITE LOGIC MODEL
ACTIVITY/TACTIC Policy and political tactics: Relationship building with professional social work and nursing organizations CAPITAL REQUIRED Human: Charisma, knowledge, skills, attitude, and ability to be transparent Social: Connect with agencies, decision makers, academicians, ability to market/package proposal, influence Economic: Paying for innovative tools/applications: 7 hours Communication and outreach: Coalition and network building Sociotechnical to use networking tools: 8 hours Sending emails, creating website, utilizing social networking applications, calling, writing, and joining an organization’s advocacy efforts: 2 hours Consensus: Not a priority for the agency: 1 hour 11 hours TIME REQUIRED Meeting heavy: 4 hours FEASIBILITY Having systems, expertise, and time in place to conduct activities: 5 hours TOTAL 16 hours

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TABLE 2

EVALUATING THE CONTEXT
EXTERNAL ASSETS 1. Public health insurance (Medicare and MediCal) 2. Public university-affiliated health care system 3. Evidence-based research LIABILITIES 1. Weak health care infrastructure in place 2. Lack of monitoring and health care outcomes by the public system 3. Lack of continuity of care with public health care plans 4. Lack of interoperable computerized records 5. Lack of integrated systems of care 6. Lack of electronic portals INTERNAL ASSETS Ms. Smith saw flyers/pamphlet about Simms/ Mann services and self-referred. Simms/Mann provides psychological, emotional, and integrative services that combine integrative and conventional treatments. Simms/Mann provided social work intervention services on site. Simms/Mann social work intern was knowledgeable in case advocacy. LIABILITIES Ms. Smith’s oncologist did not refer her case to social work. The Center can only provide oncology related services and resources. Oncologist does not discuss advance care planning. Lack of integrated system of care. Lack of coordination between primary care and specialty care.

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REFERENCES American Cancer Society. (2009). Cancer facts and figures. Retrieved November 5, 2009, from www.cancer.org/docroot/STT/STT_0.asp California Healthline. (March, 2007). Designing a consumer-centered personal health record: Carol Franc Buck Breast Cancer Center at UCSF. Retrieved November 30, 2009, from www.californiahealthline.org. Carney, P. A., Eiff, P., Saultz, J. W., Douglass, A. B., Tillotson, C. J., Crane, S. D., Jones, S. M., & Green, L. A. (2009). Aspects of the patient-centered medical home currently in place: Initial findings from preparing the personal physician for practice. Journal of Family
Medicine, 41(9), 632-639.

Clark, E.J. (2009). A broader vision for the social work profession. National Association of Social Workers. Retrieved December 2, 2009, from www.naswdc.org/nasw/vision.asp. Coffman, J. (2007). Evaluation based on theories of the policy process. The Evaluation
Exchange, 13(1), 1-16.

Crawley, L. M., Ahn, D. K., & Winkleby, M. A. (2008). Perceived medical discrimination and cancer screening behaviors of racial and ethnic and minority adults. Cancer Epidemiology,
Biomarkers & Prevention, 17(8), 1937-1944.

DeAngelis, C. D. (2009). Commitment to care for the community. Journal of the American
Medical Association, 301, 1929-1930.

Dorfman, L., Sorenson, S., & Wallack, L. (2009). Working upstream: Skills for social change.
A resource guide for developing a course on advocacy for public health.

Berkeley, Media Studies. Herman, C. (2009). Biopsychosocial challenges related to transitions of care. National Association of Social Workers. Retrieved December 3, 2009, from socialworkers.org. Jansson, B. S. (2008). Becoming an effective policy advocate. Belmont, California: Thomsson Brooks/Cole. Jansson, B. (In preparation). Draft of chapter 3 in forthcoming book, An advocacy framework:
Tasks, skills, and actions. Hoboken, New Jersey: John Wiley & Sons, 60-103.

Jansson, B. (In preparation). Draft of chapter 4 in forthcoming book, An advocacy framework:
Tasks, skills, and actions. Hoboken, New Jersey: John Wiley & Sons, 103-153.

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Kim, S. E., Perez-Stable, E. J., Wong, S., Gregorich, S., Sawaya, G., Walsh, J. M. E., & Kaplan, C. P. (2008). Association between cancer risk perception and screening behavior among diverse women. Archives of Internal Medicine, 168(7), 728-734. McDaniel S. H., & Fogarty, C. T. (2009). What primary care psychology has to offer the patientcentered medical home. Professional Psychology: Research and Practice, 40(5), 483492. Penner, L. A., Dovidio, J. F., Edmondson, D., Dailey, R. K., Markova, T., Albrecht, T. L., & Gaertner, S. L. (2009). The experience of discrimination and Black-White health disparities in medical care. Journal of Black Psychology, 35(2), 180-203. Robbins, C. L., & Birmingham, J. (2005). Issues and interventions: The social worker and nurse roles in case management. Applying the three R’s. Lippincott’s Case Management,
10 (3), 120-127.

Rosenthal, T. C. (2008). The medical home: Growing evidence to support a new approach to primary care. Journal of the American Board of Family Medicine, 21(5), 427-440. Sherman, P., Moscou, S., & Dang-Vu, C. (2009). The primary care crisis and health care reform.
Journal of Health Care for the Poor and Underserved, 20(4), 944-950.

U.S. Census Bureau. (2005). People and households. Retrieved October 20, 2009, from www.census.gov/hhes/www/income/cphls/cph1128f.html. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2008, February). National healthcare disparities report 2007. Retrieved November 10, 2009, from www.ahrq.gov/qual/qrdr07.htm#toc. Volland, P. J. (2003). Social work education for health care: Addressing practice competencies.
Journal of Social Work in Health Care, 37(4), 1-17.

Head Start and DCFS
HEATHER STEPHENS
Social Work in Public Child Welfare Settings Professor Jacquelyn McCroskey

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Through thorough observation of cases at the Department of Children and Family Services (DCFS) in Los Angeles from 2008 to 2009, it has been noted that there is a dearth of resources for homeless preschool-aged children in terms of education. Therefore, the following paper will examine the effectiveness of Head Start-type preschool programs for homeless preschool-aged youth. The research will focus particularly on the urban setting of Los Angeles, since very few, if any, Head Start research studies have been conducted in such a setting, as they usually take place in rural settings (Currie & Thomas, 1995; Reynolds, Temple, Robertson, & Mann, 2001). First, the practice arena will be discussed, followed by a review of the literature, a discussion of competing perspectives and opinions of experts, an assessment of how these issues affect child welfare practice, the contribution to disproportionality, and the writer’s perspective on the best practice.
PRACTICE ARENA

The following research hopes to acknowledge a controversial issue within the Department of Children and Family Services (DCFS). DCFS offers a multitude of services ranging from reducing the recurrence of child abuse and neglect to offering education services to families in and around the Los Angeles area. Head Start is a federally funded grant program that aims to improve the learning, social skills, and health of poor children in order to bring them up to par with their peers (Currie & Thomas, 1995; Lee, Gunn, Schnur, & Liaw, 1989). It has been referred to as one of the only long-term legacies of late President Johnson’s War on Poverty (Lee et al., 1989; Jansson, 2008). The goal of such a program was that the plan would help disadvantaged children break free from the cycle of poverty (Lee et al., 1989) and it places an emphasis on the whole child (Cole & Washington, 1986). Even more recently, both former Presidents Bush, Sr., and Clinton pledged to allocate funding so all eligible children would have access to services. Unfortunately in 1995, only 28% of eligible three- to fiveyear-olds were served (Currie & Thomas, 1995). Therefore, resources are still needed.

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In order to examine the gaps within DCFS, an assets mapping and needs assessment was conducted. Asset mapping and needs assessment is carried out in order to provide information about the incidence of issues that are not addressed within an agency and provides data to be used by them in advocating for their work (Netting, Kettner, & McMurtry, 2008). When examining reports conducted by different DCFS agencies, there is no mention of preschool issues within the community. However, in examining the DCFS SPA 4 scorecard it was found that out of 43,623 youths three- to five-years-of-age in the region, only 17,099 were in preschool (CPC, 2007). Therefore, only 39% of youths were enrolled in preschool in 2006-2007. Even more, Hottenroth, Strum, Woods, and Picone (2009) note that only 20% of children within child protective services are enrolled in early childhood education. Also, the need for such a program can be noted by the broader finding that only 15% of homeless preschoolers in the United States are enrolled in preschool (USDOE, 2002). Therefore, with so few children in preschool services, the assets mapping and needs assessment of DCFS found that such services are needed.
REVIEW OF THE LITERATURE

This specific population has been targeted due to the transient nature of the homeless population and the difficulty of meeting their educational needs. Many preschool-aged homeless youth are overlooked due to the enrollment barriers they face, such as lacking a stable address (LAHSA, 2008). Even programs such as Head Start, which are designed to address this poverty-stricken population, require an address to enroll (NHSA, 2008). Also, it has been found that in order for poor children to succeed academically, they need to be involved in education early (Prince, Hare, & Howard, 2001). Thus, the need for effective interventions for homeless preschool youth is even more important. When examining the literature it is noted that where one lives determines their economic success, but it should not establish it (Dreier, Mollenkopf, & Swanstrom, 2001) and this is the case in this situation as well. According to Salcido (2005) and Rafferty and

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Shinn (1991), there has been little research conducted on community collaborations for homeless youth. Hottenroth et al. (2009) have started community collaborations with Head Start that address such populations; however they do not further allocate services to the homeless. Even more, the exact number of homeless youth in the United States is unknown (Zastrow & Kirst-Ashman, 2007), but the United States is still recognized as the nation with the highest rate of child poverty (Karger & Stoesz, 2006). Further, it is estimated that over 42% of the homeless in the United States are under the age of five (LAHSC, 2008). Children are one of the fastest growing and one of the most vulnerable homeless populations (Dryness, Spoto, & Tompson, 2004). This means that something needs to be done now, while they are still young, in order to help them. According to Lynch (2007) and Reynolds et al. (2001), offering a high-quality preschool program to homeless youth will benefit the state in the end. For example, one of the main attractions of preschool is that it reduces the amount of people in the criminal system or the amount of people experiencing labor force difficulties later on in life, saving the government money in the end (Temple & Reynolds, 2007; Venkatesh, 1999). Also, for every dollar spent on early child education, seven dollars is saved in the long run (Prince, Hare, & Howard, 2001). Research has shown that when high-quality care is given before kindergarten, there is less need for specialized education services later on in K-12 (Lynch, 2007). This is important to note as Hottenroth et al. (2009) found that half of the children in DCFS caseloads have some type of learning delay or disability. Even more, it has been noted that those born into poverty have greater economic and educational attainment when they attend preschool compared to those that do not (Halle et al., 2009; Schweinhart & Weikart, 1997). Also, in a study conducted by Levin, Belfield, Muennig, & Rouse (2007), of 100 high school dropouts, it was found that if they had gone to preschool, 19 more of them would have graduated. That is 20% fewer people dropping out if they had attended preschool. Lastly, poverty has been noted

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to be one of the leading causes of dropping out of school (Bassuk et al., 1997), thus services need to take this into consideration. Further, preschool is an important aspect of one’s development, especially when looking at it from a theoretical standpoint. For example, Vygotsky, Cole, John-Steiner, Scribner, and Souberman (1978) noted that learning is achieved when one is involved in activities with others, as they are able to negotiate different meanings with these persons in their environment. They are able to reach goals by interacting with peers and their instructors (Vygotsky et al., 1997). Thus, if these homeless youth do not have access to such interactions at a young age, it is quite possible that they will be at a disadvantage in terms of cognitive development when compared to their peers that did attend preschool. Further, since they do not have this early learning experience, their language development may be at a disadvantage. Head Start research has also shown that it is important to take into consideration that it does serve the poorest of the poor and the least advantaged of children (Currie & Thomas, 1995; Lee et al., 1989; Nicholas et al., 2003). For example, it was noted by Nicholas et al. (2003) and Meisels and Atkins-Burnett (2004) that the Head Start population is composed mainly of those children whose families come from incomes below the national poverty line. Therefore, such research findings might elicit results that are not ideal or representative of the entire population. Lee et al. (1989) found that Head Start was one of the only preschool options available to poor families, and current research at DCFS has shown that this is still the case (B. Mistrano*, LCSW, personal communication, November 20, 2008). On the other hand, when well implemented, Head Start-type programs can reverse negative development for many of low-income youth (Knitzer, 2007) and reduce crime rates (Temple & Reynolds, 2007). Therefore, this just shows the importance of Head Start programs for such a disadvantaged population.

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In one study of 139 homeless children of varied ages, it was noted that they scored near or at the mentally retarded range three times more than those children that were not homeless (Douglass, 1996). Bassuk et al. (1997) and Hottenroth et al. (2009) also noted that homeless preschool children and children from protective services have more developmental delays. However, when examining a different study that was conducted on 213 homeless preschool children, their scores differed very little from the general population (Douglass, 1996). Douglass (1996) then looked at literature that compared children of low-income families to homeless children and found no real differences. The one main difference that was found in this study was that regardless of having a home or not, if they were in an early childhood education program they scored better than all children not in such programs (Douglass, 1996). Even though research findings vary, it is still apparent that preschool access is imperative to all children’s development, especially the homeless. Upon entering preschool, it was found that homeless preschool children have more health problems and emotional and behavioral difficulties than those with homes (Bassuk et al., 1997; Spernak, Schottenbauer, Ramey, & Ramey, 2006). This has been found to be attributed to lack of sleep and discomfort (Spernak et al., 2006), which correlates with the difficulty of restful sleep due to being homeless. Also, it has been linked with the stress and anxiety that results from constant moving around and relocation (Stoneman, Brody, Churchill, & Winn, 1999). Homeless children in poor health are then at an even greater risk of low academic achievement and failing in school (Spernak et al., 2006). Even worse, it was found that the housing status effect on children increases with age (Bassuk et al., 1997). Going further, homeless people do not necessarily share the same experiences. For example, children who are constantly moving around experience similar anxiety as those children who are homeless. Anxiety has been known to cause psychological effects, poor affect, and suppressed cognitive functioning (Stoneman et al., 1999). Further, Hausman

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and Hammnen (1993) noted that the experience of a homeless person is vastly different if living in a residential facility compared to an emergency shelter or a hotel or motel. Each particular environment provides a different environmental constraint (Hausman & Hammnen, 1993). Douglass (1996) even found that those in low-income housing are often referred to as homeless, so this may skew data as well. Another issue presented by the research is that since there are so many different classifications of homeless, it becomes a problem when all homeless are treated as a homogenous group (Cole & Washington, 1986).
COMPETING PERSPECTIVES AND OPINIONS OF EXPERTS

In personal communication with Peter Storm*, who specializes in DCFS educational programs, it was stated that in all of Los Angeles, only 34% of three- to four-yearolds are in preschool (personal communication, February 9, 2009). This statistic raises questions. When asked if he thought access to preschool for homeless clients at DCFS was a problem, Peter Storm* stated, “It is definitely a problem and DCFS has yet to address it” (personal communication, February 9, 2009). More recently, Hottenroth et al. (2009) began to address the disparity in access to Head Start services for DCFS clients, but more needs to be done in order to assure that all clients have the chance to use such resources. More specifically, Hottenroth et al. (2009) identified190 children within DCFS caseloads in the El Monte, California area as being eligible for free preschool; out of that, 58 applications were sent in for services and 15 were accepted. If the overall population is having difficulty attending preschool, how can one expect the homeless population within DCFS to be any different? Going further, when contacting Los Angeles Unified School District (LAUSD) educational services worker, Veronica Girgin*, it was found that their records showed only 24 homeless children enrolled in preschool classes in all of Los Angeles (personal communication, February 9, 2009). These numbers are very low, and one wonders why so many of these

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homeless youth are not being assisted by Head Start through referrals by DCFS. Even more, why do schools have a record of so few homeless youths? Also, guest lecturer, Lilia Guirguis, the director of Magnolia Place Community Initiative, stated that one of their four goals to address within the community was to have their children ready for kindergarten (personal communication, November 24, 2009). Just in their 500-block service area alone they have 10,000 zero- to five-year-old children (L. Guirguis, personal communication). Therefore, even community partners outside of DCFS are identifying this as a service area that needs help. However, guest lecturer Jack Coven* from Head Start stated that the homeless population has priority access to services within Head Start (personal communication, October 13, 2009). When communicating with DCFS social worker, Monica Sanchez* (personal communication, February 11, 2009), she was under the impression that her homeless clients had to reapply to Head Start each time they moved. Further, DCFS social worker Monica Sanchez* stated she did not feel access to preschool was a problem within DCFS (personal communication, February 11, 2009). She acknowledged she knew preschool was optional, and for her clients who were homeless this was not her top concern. Thus, there are differing opinions when it comes to the experts and workers in the field. From firsthand experience interning at DCFS, I did not find that my clients had priority access. My two clients were homeless, moving around from relative to relative. They never had a chance to start Head Start as they were on the waiting list and constantly moving, which forced them to have to be placed on another waiting list. No one ever said they should be granted priority access to preschool services.
ASSESSMENT OF THE EFFECTS ON CHILD WELFARE PRACTICE

From working firsthand with social workers at DCFS and communicating with

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professionals in the field, it is clear why there is confusion on which information is accurate in regards to homeless preschool youth. According to DCFS staff member, Barbara Mistrano*, many of the social workers have to spend a lot of time planning what to do with such clients, and a majority of them still believe that their homeless preschool youth either do not qualify for services or they have to be placed on a waiting list like the rest of the clients (personal communication, February 11, 2009). Thus, this issue deeply affects the practice of working with such clientele. Therefore, much more outreach and training needs to be done in order to further educate the case workers about where to refer their clients. Further, when communicating with some Head Start offices directly, they too confirmed that one needs an address to even be placed on the waiting lists (personal communication, February 9, 2009); thus, such regulations need to be further clarified. Once a collaboration between DCFS and Head Start was made, problems would continue to arise. For example, Hottenroth et al. (2009) note that there are approximately 15,000 youths aged zero to five in and out of foster care, which means there are not enough homeless preschool programs for all of them to attend. In the future, more preschool programs may need to be created to further address this issue. With all of the confusion and challenges, there are many pros that would come from such collaboration. For example, once the social workers were updated on how to deal with this population, they would have acquired more knowledge, which would help them to address community problems. Also, this new collaboration between DCFS and Head Start would bring about a more innovative multidisciplinary approach that could only assist DCFS in the long run.
DISPROPORTIONALITY

In terms of cultural diversity, DCFS sees a wide array of ethnic backgrounds (CPC, 2007). Interestingly, most of the research conducted on homeless preschool youth has focused

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on African-American children (Currie & Thomas, 1995). Thus some of the findings may not be as applicable to the population of Los Angeles. Also, according to Hausman and Hammnen (1993), the cultures of homeless people are different. For example, each homeless family is homeless for different reasons and will have varied experiences while being homeless. Thus, each homeless family has a different homeless culture. Therefore, when assessing the needs and the culture of the homeless, preschool-aged DCFS clients, their individual backgrounds need to be considered. For example, some of these children may be living with relatives while some may be living in cars, causing their specific education needs to vary. This background needs to be taken into consideration when creating such programs.
BEST PRACTICE

I personally believe that all children, regardless of economic standing, should have access to the best preschool available. Even more, research is showing that what children learn before the age of five is of utmost importance and shapes them for the rest of their lives. Therefore, something needs to be done soon to further acknowledge the lack of access. With this being said, I feel that DCFS is behind in recognizing the need for such services. Also, there is a barrier in communication between Head Start and DCFS, as both organizations show confusion about their roles in addressing the homeless preschool-aged population. Therefore, I feel when it comes to best practice, DCFS should have priority in placing children at Head Start for preschool services, and more collaboration needs to be done.
*Some names have been changed to protect privacy.

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REFERENCES Bassuk, E.L., Buckner, J.C., Weinreb, L.B., Browne, A., Bassuk, S.S., Dawson, R., Perloff, J. N. (1997). Homelessness in female-headed families: Childhood and adult risk and protective factors. American Journal of Public Health, 87(2), 241-248. Cole, O.J., & Washington, V. (1986). A critical analysis of the assessment of the effects of Head Start on minority children. The Journal of Negro Education, 55. CPC. (2007). Children’s planning council: Scorecard 2006-2007. Retrieved September 25, 2008 from publichealth.lacounty.gov/childpc/localspa4.htm. Currie, J., & Thomas, D. (1995). Does Head Start make a difference? The American
Economic Review, 85(3).

Douglass, A. (1996). Rethinking the effects of homelessness on children: Resiliency and competency. Child Welfare, 75(6). Dreier, P., Mollenkopf, J., & Swanstrom, T. (2001). Place matters. University Press of Kansas. Dryness, R.C., Spoto, P., & Tompson, M. (2004). Crisis on the streets: Homeless women and children in Los Angeles. In Salcido, R. M. Para los ninos: A children and youth services agency. Child Welfare Section Connection. NASW. Spring 2005: 6-9. Halle, T., Forry, N., Hair, E., Perper, K., Wandner, L., …Vick, J. (2009). Disparities in early learning and development: Lessons from the early childhood longitudinal study-birth cohort (ecls-b). Child trends: Executive summary. Hausman, B. & Hammnen, C. (1993). Parenting in homeless families: The double crisis.
American Journal Orthopsychiatry, 63(3).

Hottenroth, J., Strum, S.J., Woods, K., & Picone, M. (2009). Pomona and El Monte areas
joint collaboration between Lacoe Head Start and DCFS [PowerPoint

presentation]. Jansson, B.S. (2008). Becoming an effective policy advocate: From policy practice to
social justice (5th ed). Belmont, CA: Thomson Higher Education.

Karger, H.J. & Stoesz, D., (2006). American social welfare policy: A pluralist
approach (5th ed). Boston MA: Allyn & Bacon.

Knitzer, J. (2007). Putting knowledge into policy: Toward an infant-toddler policy agenda.
Infant Mental Health Journal, 28(2), 237-245.

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LAHSA (2008). Los Angeles Homeless Services Authority. Retrieved October, 24 2008, from www.lahsa.org. LAHSC. (2008). Los Angeles Homeless Services Coalition. Retrieved November 17, 2008 from lahsc.org/wordpress/educate/statistics. Lee, V.E., Gunn, J.B., Schnur, E., & Liaw, F.R. (1989). Are Head Start effects sustained? A
longitudinal comparison of disadvantaged children attending Head Start, no preschool, and other preschool programs. Michigan: USDOE.

Levin, H., Belfield, C., Muennig, P., & Rouse, C. (2007). The costs and benefits of an excellent education for all of America’s children. New York: Leeds Foundation. Lynch, G. (2007). Enriching children, enriching the nation: Public investment in highquality prekindergarten. New Hampshire: Economic Policy Institute.

Meisels, S.J., & Atkins-Burnett, S. (2004). The Head Start national reporting system: A critique. Public policy viewpoint: Young children on the Web. Netting, F.E., Kettner, P., & McMurty, S. L. (2008). Social work macro practice (4th ed.). Boston: Pearson. NHSA (2008). National Head Start Association. Retrieved November 17, 2008 from www.nhsa.org/. Nicholas, Z., Resnick, G., Kim, G., O’Donnel, K., Sorongon, A., McKey, R. H., Pai-Samant, S., … D’Elio, M. A.(2003). Head Start faces 2000: A whole-child perspective on program administration. Administration for children, youth, and
families. Washington, DC: DHHS.

Prince, D.L., Hare, R.D., & Howard, E.M. (2001). Longitudinal effects of kindergarten.
Journal of Research in Childhood Education, 16.

Rafferty, Y., & Shinn, M. (1991). The impact of homelessness on children. American
Psychologist, 46(11), 1170-1179.

Reynolds, A.J., Temple, J.A., Robertson, D.L., & Mann, E.A. (2001). Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: A 15-year follow-up of low-income children in public schools. Journal of
American Medical Association, 285(18).

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Salcido, R.M. (2005). Para los ninos: A children and youth services agency. Child Welfare
Section Connection. NASW. Spring 2005: 6-9.

Schweinhart, L.J., & Weikart, D.P. (1997). The high/scope preschool curriculum comparison study through age 23. Early Childhood Research Quarterly, 12, 117-143. Spernak, S.M., Schottenbauer, M.A., Ramey, S.L., & Ramey, C.T. (2006). Child health and academic achievement among former Head Start children. Children and Youth
Services Review, 28, 1251-1261.

Stoneman, Z., Brody, G.H., Churchill, S.L., & Winn, L.L. (1999). Effects of residential instability on Head Start children and their relationships with older siblings: Influences of child emotionality and conflict between caregivers. Child
Development, 70(5).

Temple, J.A., & Reynolds, A.J. (2007). Benefits and costs of investments in preschool education: Evidence from the child-parent centers and related programs.
Economics of Education Review, 26, 126-144.

USDOE. (2003). Homeless education advisory 2003. Retrieved November 17, 2008 from www.doe.mass.edu/mv/haa/03_6.html. Venkatesh, S.A. (1999). Community-based interventions into street gang activity. Journal
of Community Psychology, 27(5), 551-567.

Vygotsky, L.S., Cole, M., John-Steiner, V., Scribner, S., & Souberman, E. (1978). Mind in
society. Cambridge, MA: Harvard University Press.

Zastrow, C., & Kirst-Ashman, K.K. (2007). Understanding human behavior and the social
environment (7th ed.). Belmont, CA: Thomson.

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Policy Analysis of the Gang Violence and Juvenile Crime Prevention Act
IMAN A. TURNER
Policy and Practice in Social Service Organizations Professor Heather Moore

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INTRODUCTION

Since the 1970s, there has been a sharp rise in the number of juvenile offenders being transferred to adult courts. This increase in transferred youths was a response to the increase of juvenile crimes in the 1970s and 1980s. The main social welfare issue that prompted this increase in juvenile transfers was the concern for public safety and serving justice to the victims by holding these juvenile offenders just as accountable for their actions as their adult counterparts (Backstrom, Walker, 2005). In California alone it was estimated that 6,629 youths were charged as adult offenders from 1989-2003 (Fagan, 2008). Another survey indicated that twenty-five percent of all juvenile cases are transferred to adult courts (Fagan, 2008). Although the magnitude of this issue continues to be quite pervasive within the legal field, whether the effect of transferring youths to adult courts is more beneficial or detrimental for society as a whole continues to be debated. Since this peak in juvenile crime, various data have been presented by scholars and professionals illustrating either the strengths or weaknesses of the policies that allow juvenile courts to transfer youths to adult courts. However, the larger policy question that will be analyzed in this paper is whether juvenile offenders should be tried as adults in the courts. And if so, at what age is this appropriate? By looking at this social welfare issue from a macro point of view, we are able to first determine whether this policy holds any validity before delving into how to improve or alter a policy that may in essence call for complete removal.
POLICY ANALYSIS

The policy that has had a significant impact on the transferring of juvenile offenders to adult courts is the Gang Violence and Juvenile Crime Prevention Act of 1998 (Hannan, 2008). The implementation of this law was to address the increasing severity of crimes committed by juvenile offenders. In 1996 the United States Department of Justice reported that the rate at which juvenile offenders were being arrested for serious crimes

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increased by 46 percent from 1983 to 1992, while murders committed by juvenile offenders more than doubled during this same time period (Ezell, 2007). These alarming statistics made it apparent that something needed to be done about the growing problem of young offenders. Although juvenile courts have always had the jurisdiction to waive their rights in presiding over a “violent or serious” juvenile case, the Gang Violence and Prevention Act further expanded this right. This act redefined which crimes were considered violent or serious, which ultimately led to longer prison sentences and an increase in the number of juvenile offenders being susceptible to the Three Strikes law. Prior to the Gang Violence and Juvenile Crime Prevention Act, juvenile offenders 14 or older could be tried as adults for certain offenses. However, in order for a transfer to take place the prosecutor had to file a petition with the juvenile court requesting the juvenile be transferred to adult court for prosecution. After this petition was submitted to the juvenile courts, a hearing was held to determine whether the minor should be transferred. If the individual in question already had a prior violent or serious criminal offense their case would automatically be transferred to the adult court system (Hannan, 2008). After the implementation of the Gang Violence and Prevention Act, juvenile offenders 14 or older who were charged with committing certain types of murder or serious sex crimes were no longer eligible to have their case presided over by the juvenile courts. This act also allowed prosecutors to directly file adult charges against minors, without the juvenile courts waiving their jurisdiction or conducting a hearing on whether the youth’s case should be transferred to adult court (Hannan, 2008). This act also eradicated the jurisdiction of probation departments to determine whether juvenile offenders arrested for a serious or violent crime should be released or detained until their case could be brought before a judge; under this act the detention of these juveniles is required.

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On the surface the goals of this policy seem to be legitimate and well-founded. However, when analyzing this policy from a systematic approach, it appears to be riddled with flaws and loopholes. Research illustrates that juvenile crime rates have not declined since the implementation of this policy. Many of these juvenile offenders end up worse after they are incarcerated in adult prisons and are more likely to reoffend once released back into the community (Burrow, 2008). Despite the overwhelming evidence suggesting this policy is not positively affecting the community or decreasing the number of crimes committed by these minors, this system of transferring youths continues to be quite prevalent within the juvenile system. Rather than benefiting the community, as the Gang Violence and Prevention Act proposed to do, it is actually causing a fiscal deficit for the community. Prior to the implementation of this act it was estimated that the annual operating costs for counties to house these juvenile offenders prior to being transferred to adult court could range from tens of millions of dollars to more than $100 million, with one-time construction costs of $200 million to $300 million. Given the free discretion at which this policy is currently being used by prosecutors and the courts, these fiscal estimates have most likely substantially increased (Burrow, 2008).
POLICY IMPACT ON THE COMMUNITY

The implications of this policy on the Crenshaw community are quite significant. Studies have illustrated that poverty and dropout rates have been directly linked with crime rates. Many of the individuals living in the Crenshaw community are living below poverty levels. This policy has also had a significant impact on African American and Hispanic males. Research indicates that 95% of the cases that have been waived by juvenile courts involved members of a minority background (Macallair, Males, 2000). The Crenshaw population is 73.34% African American and 16.89% Latino. Minority youths are 2.7 times more likely to be arrested for a violent felony and 3.1 times more likely to have their case transferred to adult courts than their white counterparts (Macallair, Males, 2000).

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Due to the fact that youths residing in the Crenshaw area are more likely to be subjected to the adult legal system, there is also a stigma associated with these youths and the general idea that many of them are “unredeemable,” which creates a bias that has the ability to spill over into the courts. They are more likely to receive longer sentences and like many youths from disadvantaged backgrounds are not provided the psychological support that they may require. The resolution of this policy will have a significant effect on youths in the Crenshaw community because many of them are more susceptible to falling victim to this system of transference. By restructuring the implications of this policy many of these youths will be provided other services and options to fulfill the consequences of the crimes they have committed and be successfully rehabilitated back into the community.
POLICY QUESTION

The policies put in place through the Gang Violence and Juvenile Crime Prevention Act have shaped the way in which many juvenile offenders are processed within the legal system. This act has caused a sharp divide between those who support and those who oppose the changes implemented through this act. A key policy question being presented to these opposing sides is, “At what point should juvenile offenders be tried as adults? Or should they?” On one side of the debate you have the individuals who support the policy of transferring juvenile offenders to adult courts for crimes that are considered heinous. From this perspective it is argued that juvenile offenders should be held accountable for their actions and be adequately punished regardless of their age. These supporters argue that in analyzing whether juveniles should be processed in adult court it is imperative to take into account the larger issue at hand. The very essence of the legal system is to provide justice to individuals and communities who have been victimized, regardless of the age, gender, or ethnicity of these individuals or groups.

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These supporters also argue that age alone should not be a mitigating factor in deciding whether a minor should be sentenced in a juvenile or adult court. Many supporters have argued “the primary factors affecting a juvenile’s sentence should be the seriousness of the crime and the protection of the community from harm, and accountability to the victim and the public for the juvenile’s behavior” (Backstrom, Walker, 2005). Another argument that has been discussed by those who support the transferring of juvenile offenders to adult court is the idea that probation, which is often the sanction issued to youths in a juvenile system, is not an extreme enough punishment for serious, violent, or repeat juvenile offenders. On the opposing side of this debate are individuals who do not think the policy of transferring juveniles to adult courts poses any direct benefit for these youths or for society as a whole. The juvenile system was established based the assumption that these youths were less capable of understanding the severity of their crimes and were more likely than adults to be driven by emotions and peer pressure but were also more open to rehabilitation (Park, 2008). This side of the debate emphasizes the fact that transferred youths are typically subjected to longer waiting periods before their cases are adjudicated or reach a guilty or innocent verdict. The argument from this opposing side is that detaining these youths for extended periods of time before reaching verdicts makes them more susceptible to developing psychiatric problems and suicidal behaviors (Abram, McClelland, Simon, Teplin, Voss, Washburn 2008). One study that took place in Illinois found that 65% of transferred youths had or developed some type of a psychiatric problem prior to or while in prison. This same study found that only 34% of adult inmates were found to be suffering from similar psychological problems (Abram, McClelland, Simon, Teplin, Voss, Washburn 2008). Despite the high rates of psychiatric problems found in these youths, studies have indicated that only a small portion of them are offered psychiatric services prior to being sentenced in adult court or after being sent to prison (Abram, McClelland, Simon, Teplin,

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Voss, Washburn 2008). This opposing side argues that one of the major problems with the lack of psychiatric support offered to these youths is that the majority of these youths will eventually be released back into the general public, in a worse state than they were in prior to being transferred to an adult facility (Abram, McClelland, Simon, Teplin, Voss, Washburn 2008). Research also indicates that transferred youths are more likely to reoffend earlier and be involved in violent crimes in comparison to youths who remained in the juvenile justice system, which ultimately contradicts the very essence of the legal system (Abram, McClelland, Simon, Teplin, Voss, Washburn 2008). This side of the debate also argues that the juvenile court’s option to waive their jurisdiction over a case was previously deemed unconstitutional under the Kent v. United States Supreme Court case. The implementation of this case required a full investigation be conducted prior to allowing juvenile courts to waive their rights over he case in question. However, waivers that are considered “statutory or mandatory” are automatically transferred to adult court without a prior hearing (Park, 2008).
RECOMMENDATIONS AND CONCLUSIONS

In analyzing the policy question “When should juvenile offenders be tried as adults in the court? Or should they?” it is important to look at the implications and efficacy of this policy. The expansion of the practice of transferring youths to adult courts took place during a time when the rate of serious and violent crimes committed by juvenile offenders was at its peak. The initial goal of this policy was to increase public safety by taking these dangerous offenders off the streets. However, an overwhelming amount of research surrounding the transferring of juvenile offenders to adult courts indicates that this process has not increased public safety and in many ways has been more detrimental to both the juvenile offenders and the community this policy was established to protect. The Gang Violence and Juvenile Crime Prevention Act became a law in 2000, and since its implementation the goals of this policy still remain unaccomplished. After nine years

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of failing to meet its policy goals, it seems rational to reanalyze this policy and question the purpose of its implementation. There have been no significant achievements since this policy was put in place, and in many ways it has only exacerbated the problem by increasing the likelihood of juveniles to reoffend. Many of the juveniles who do not reoffend once released back into the general public are psychologically impaired from the victimization they were forced to endure while incarcerated with adult inmates. The purpose of this policy is to teach these juvenile offenders a lesson and provide justice to the victims of their crimes. Those who are considered “redeemable” are rehabilitated and released back into the community, but as Judge Skelly Wright states, “a child is unlikely to succeed in the long, difficult process of rehabilitation when his teachers during his confinement are adult criminals” (Park, p. 809). I do not doubt that at one point the intention of this policy may have been to create a safer society overall, but at this point it seems as though this policy is taking on a “BandAid” effect. Transferring these youths to adult courts is a quick fix or cover up for the problem at hand. Although the problem remains, by transferring an increasing number of youths to adult courts, it makes it appear as though this policy is successfully removing dangerous offenders from the society they threaten. There are various avenues that can be taken to address the issue of public safety and the possible threats certain juvenile offenders may pose. Regardless of what avenue of change is taken, one of the first steps is to do away with this “Band-Aid” effect that has a tendency to conceal the root of the problem. Transferring youths to adult courts is not decreasing the crime rate or increasing the likelihood that they will be rehabilitated, so why does this policy continue to exist? This is the core question that needs to be addressed to bring about a positive change in the rehabilitation of these young offenders and ultimately the safety of society as a whole.

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Rather than transferring these youths to adult courts, perhaps the expansion of the juvenile courts’ jurisdiction to preside over serious or violent crime offenders would be more appropriate. I firmly believe these youths should be held accountable for their actions, but ultimately the aim should be rehabilitation not punishment. It is imperative to look at each case on an individual basis and understand the history of the individual in question and why he or she is engaging in this type of behavior. Trying to get to the root of the problem and understand why the crime was committed in the first place is crucial for understanding how to establish a successful policy for change.

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REFERENCES Abram, K., McClelland, G. Simon, C., Teplin, L., Voss, L., Washburn, J. (2008). Psychiatric disorders among detained youths: A comparison of youths processed in juvenile court and adult criminal court. Psychiatric Services, 59(9), pp. 965-973. Retrieved from ps.psychiatryonline.org. Backstrom, J., Walker, G. (2005). The role of the prosecutor in juvenile justice:
Advocacy in the courtroom and leadership in the community. pp. 964-987

Burrow, J. (2008). Reverse waiver and the effects of legal, statutory, and secondary legal factors on sentencing outcomes for juvenile offenders. Crime & Delinquency,
54, pp. 34-64.

Ezell, M. (2007). The effect of criminal history variables on the process of desistance In adulthood among serious youthful offenders. Journal of Contemporary
Criminal Justice, 23(1), pp. 28-49.

Fagan, J. (2008) Juvenile crime and criminal justice: Resolving border disputes.
The Future of Children, 18(2), Juvenile Justice, pp. 81-118.

Hannan, W. (2008). Judicial waiver as the only equitable method to transfer juvenile offenders to criminal court. Notre Dame Journal of Law, Ethics & Public Policy,
22, pp. 192-223.

Macallair, D., Males, M., (2000) The color of justice: An analysis of juvenile adult court transfer in California. Building blocks for youth, for fair and effective
youth justice system, pp.1-11

Park, J. (2008). Balancing rehabilitation and punishment: A legislative solution for unconstitutional juvenile waiver policies. A Legislative Solution for Juvenile
Waiver Policies, 76(3), pp.786-818.

Woo, B. (2007). Cudgel or carrot: How Roper v. Simmons will affect plea bargaining in the juvenile system. Pepperdine Dispute Resolution Law Journal,
7(3), pp.475-498.

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Childhood Obesity in America
KRYSTAL WANG
Advanced Theories and Clinical Interventions in Health Care Professor Julie Cederbaum

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THE EPIDEMIC IN THE UNITED STATES

As a leading nation of the world, the United States is one of the wealthiest and most progressive countries, with innovative technological advancement that continues to improve the health and well-being of Americans. Despite its level of social and economic development, obesity has become a growing health problem that plagues the lives of many in the U.S. Obesity is not a recent phenomenon in the U.S. but has been prevalent since industrialization (Edmund, 2006). From the Industrial Revolution to the present day, the quality of life of individuals has drastically increased due to economic growth, urbanization, and globalization. The classification of obesity is commonly measured by using the body mass index (BMI). The BMI is a mathematical calculation that is based on an individual’s height and weight (BMI = kg/m2). According to the World Health Organization Report (2009), an individual is categorized as “obese” with a BMI of 30 or greater. During the past few decades, there has been a dramatic increase in obesity in the United States. In 2003, the United States was ranked the most overweight country in the world, with approximately 30.6 percent of Americans suffering from obesity (Streib, 2007). By 2007, the United States ranked ninth with 74.1 percent of individuals aged 15 and over considered overweight, with a BMI of over 25 (Streib, 2007). Even though the United States is no longer the “fattest country,” the nation’s waistline is not shrinking; instead it continues to grow at a steady pace. In 2008, 26.1 percent of U.S. adults were obese, compared to 25.6 percent in 2007 (Hitti, 2009). According to a 2009 Centers for Disease Control and Prevention (CDC) report, obesity in adults has increased by 60 percent within the past twenty years, while obesity in children has tripled in the past thirty years.
OBESITY AND CHILDREN

The real threat from obesity does not come from being overweight or having excessive body fat, but from the numerous health problems associated with obesity. The National Health and Nutrition Examination Survey (NHANES) showed the prevalence of obesity for

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children between ages two and five increased from five percent to 12.4 percent between the period of 1976-1980 and 2003-2006 (Overweight and Obesity, 2009). Meanwhile, obesity in children aged six to11 increased from 6.5 percent to 17 percent; for those aged 12 to 19, prevalence increased from five percent to 17.6 percent (CDC, 2009). Since 1980, childhood obesity has tripled, with approximately nine million children ages six to nine (16 percent) classified as overweight or obese (CDC, 2009). Obesity has become an epidemic not only in the United States, but in the global community as well, with an estimated 22 million children under five years old, overweight, or obese (World Health Organization, 2009). Children who suffer from obesity will most likely stay obese into adulthood and develop non-communicable diseases (NCGs), such as cardiovascular diseases and diabetes at an earlier age. Given the facts and data presented, childhood obesity can no longer be viewed as an individual and/or a family problem, but rather as a national health crisis that could plague the U.S. into the future. This paper will primarily focus on the correlation between childhood obesity and low-income families with limited or no access to health and wellness services.
CONTRIBUTING FACTORS TO CHILDHOOD OBESITY

Childhood obesity is a major health problem that causes short- and long-term physical, psychological, and emotional harm to children. Childhood obesity increases morbidity and mortality, due to the various risks and development of chronic illnesses, such as cardiovascular diseases. In addition, children with obesity are at risk for associated adult health problems, including heart disease, type 2 diabetes, stroke, and osteoarthritis (CDC, 2009). For many years, the contributing causes of obesity were overconsumption of calories and inactivity (CDC, 2009). As a result, parents and children were blamed for obesity due to lack of impulse control. However, the causes of obesity are enmeshed with

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various components, such as genetic, biological, environmental, behavioral, and cultural factors. Research has indicated that children whose parents are obese will have a higher chance of becoming overweight or obese themselves; a family history of obesity can increase a person’s chances of becoming obese by about 25 to 30 percent (CDC, 2006). While heredity does not mean a child is destined to be obese, by managing the amount of body mass and fat distribution, childhood obesity can be prevented. Though genetic predispositions, metabolic determinants, and lifestyle choices are major factors contributing to obesity, socioeconomic status (SES) plays a crucial role.
LOW SOCIOECONOMIC STATUS MINORITY FAMILIES

Like many health disparities in the United States, childhood obesity is linked to inequalities in education and income that are most prevalent in low SES minority families. According to Drewnowksi and Specter (2004), the prevalence of obesity falls disproportionately upon individuals and families with limited resources as well as upon racial or ethnic minorities. Drewnowski and Rolls hypothesize that obesity is mainly attributed to higher-energy dense foods consumed by low-income consumers (as cited in Townsend, 2006). Higher-energy dense food is defined by the number of calories in a food’s given weight, which can be calculated using a formula (Energy Density = calories per serving / weight of serving in grams) (Drewnowksi & Specter, 2004). Thus, higher-energy dense foods consist of high calories, more fat content, and less water. Foods with high moisture content, such as fruits and vegetables, allow individuals to feel fuller, despite having fewer calories (Drewnowksi & Specter, 2004). However, prices and incomes affect individual food choices and the quality of the food. Thus, families with lower SES tend to have diets with less nutrition than wealthier households. On average, low-income households do not meet federal recommendations for consumption of fruits, vegetables, low-fat dairy products, and whole grains (Stewart & Blisard, 2008). In addition, households with income below 130 percent of the poverty line not only spend less on fruits and vegetables, but are also unlikely to increase their spending on these items if they receive additional income (Blisard et al., 2004). Steward & Blisard

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(2008) show the total weekly food spending of low-income households (LI), middleincome households (MI), and high-income households (HI) in 2003. Their data shows low-income households spend less than middle-income households on food: $33.90 per person compared with $44.39 per person (Steward & Blisard, 2008). Similarly, a smaller percentage of low-income households reported spending money on seven common foods, including beef (55 percent of low-income households, compared with 59 percent of middle-income and 61 percent of high-income households) and vegetables (77 percent of low-income households, compared with 83 percent of middle-income and 86 percent of high-income households) (Steward & Blisard, 2008). The data suggest that not only are low-income households spending less on food, but they also consume low-quality, non-healthy food. Food that includes oil, fat, sugar, and refined grains can be produced at a minimal cost compared to fresh fruits and vegetables. As a result, high density products are cheaper and more economically friendly for low-income consumers. Similarly, analysis suggests that childhood obesity is higher among lower socioeconomic families due to food insecurity. The U.S. Department of Agriculture (USDA) defines food insecurity as “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways (as cited in Alaimo, Olso, & Frongillo, 1161 and 2001). Families facing food insecurity may be categorized under low food security or very low food security (Food Security in the United States, 2009). Households with low food security may experience some cutbacks in quality, variety, or desirability in their diets. However, there is little or no evidence of reduced food intake. On the other hand, the eating patterns of households with very low food security are severely disrupted due to the reduction of food intake as a result of limited financial resources (USDA, 2009). In 2008, 85.4 percent of U.S. households reported that they were food secure throughout the year (Nord, Andrews, & Carlson, 2009). Despite the data and figures, in 2008 the USDA reported that 14.6 percent (17 million) households were food insecure compared to 12 percent of U.S. households in 1995 (Nord, Andrews, & Carlson, 2009 & Alaimo, Olso, & Frongillo, 2001). Similarly, food

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insecurity was more than four times as prevalent in households with annual incomes below 185 percent of the poverty line in 2008 (Nord, Andrews, & Carlson, 2009). As a result, there is a correlation between food insecurity and poverty due to financial constraints and minimal access to community resources. The concept of food insecurity encompasses inadequate quantities and quality of nutrients available in the household. Thus, low-income consumers and families are unable to purchase necessary food and ingredients to maintain a nutritious diet. As a result, low-income consumers decide to spend money on less expensive, high-energy foods, because they are filling. Inexpensive, high-energy foods are not only cost-effective for low-income and food-insecure families but are able to satisfy their immediate hunger needs, since they are able to consume large quantities at an inexpensive price. The consumption of starches, salt, sugar, and fats is extremely unhealthy for infants and children. According to Cook and Frank (2008), for children with smaller stomach capacity, excessive eating and overindulgence in poor, low-cost foods (such as sweetened liquids and french fries) leads to obesity, nutritional short stature, and iron deficiency anemia. Food insecurity not only influences one’s health and development, but creates stressors within the family, such as illnesses related to childhood obesity, impaired cognitive skills, and depressive symptoms. Food insecurity not only harms children during developmental stages and life cycle, but also exposes them to physical, psychological, and emotional damage. Recognizing the correlation between childhood obesity, poverty, and food insecurity, the U.S. government has implemented policies and established programs in hopes of alleviating the problem.
POLICIES, INTERVENTIONS, AND CHILDREN’S HEALTH

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM Since the passage of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in 1996, the U.S. government has made significant changes in policy creation and practices to help low-income families, such as Temporary Assistance to

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Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP) (historically known as the Food Stamp Program). Despite the federal food assistance programs, some research supposed that programs like the Food Stamp Program may have played a role in the childhood obesity-food insecurity paradox. For many years, the Food Stamp Program has been criticized for providing food stamp recipients with low-nutrient, high-energy dense food products (Townsend, 2006). Even though the intentions of the program were positive (providing for the nutritional needs of low-income families), the quality of food was often poor. Oftentimes, the Food Stamp Program required individuals to select food from an inclusion list (that designates the food types and the brands that are available for purchase). Similarly, fresh fruits and vegetables were not an option for food stamp recipients (Townsend, 2006). Therefore, low-income families under the Food Stamp Program were given low-quality food (limited to only certain types of foods). Since the establishment of the Food Stamp Program in 1939, it evolved into a $20 billion food intervention. In October 1, 2008, SNAP became the new federal food stamp program; it meets the nutritional needs of over 32 million people each month (approximately 10 percent of the U.S.’s population) (SNAP, 2009). Other than the name change, SNAP recipients witnessed an increase in minimum monthly benefit (from $10 to $14); retirement and education accounts were no longer considered as countable resources; and all dependent care costs (child care, elder care, and/or disabled household members) were taken into consideration when determining eligibility and benefit amount (SNAP, 2009). In comparison to the Food Stamp Program, SNAP provides a greater range of food selection for low-income families. SNAP benefits can be used to purchase fresh produce, meats, fish, poultry, and dairy products from authorized vendors. Families can also use their SNAP benefit on seeds and plants to grow food, as long as it is for household use and consumption. In addition, special programs from individual states authorize restaurants, nutritional and weight-loss systems (Ensure, Slim Fast, and Nutrisystem), and delivery services (such as Meals on Wheels program) to accept SNAP benefits from qualified elderly, disabled, and homeless individuals (SNAP, 2009).

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THINK GLOBALLY, ACT LOCALLY

SOCIAL WORKERS’ ROLES IN CHILDHOOD OBESITY PREVENTION AND INTERVENTION Unlike adults, it is essential for children to acquire appropriate nutrients crucial to their growth and development. By consuming adequate calories for daily activities, growth, and metabolism, children are able to reach to their full potential. However, overconsumption, inactivity, and excessive body fat creation puts the child at risk for obesity, which leads to multiple health problems throughout their lives. Looking at it from a multidimensional perspective, environmental conditions, biological factors, and psychological schemas must be taken into account. Thus, childhood obesity prevention and intervention are best conceptualized collectively rather than individually. According to Erik Erikson’s Stages of Development, the family environment is childrens’ first experience as part of the social world, in which they develop a sense of self through their caretakers (Zastrow & Kirst-Ashman, 2007). The early years of development are critical periods for the family in providing appropriate care and meeting children’s essential needs. As a result, the family is responsible for basic development and socialization of a child’s learning and behavior. For children residing in a chaotic family dynamic (who are exposed to multiple stressors that threaten their homeostasis) are at greater risk of developing childhood obesity. Stressors include: physical stressors (trauma), physiologic stressors (hemorrhagic shock), social stressors (personal conflicts and lifestyle changes), psychological or emotional stressors (anxiety and fear) (Torres & Nowson, 2007). Lacking family resilience, children in distressed households may develop maladaptive coping skills and associate food consumption with emotional survival and comfort. According to Gibson (2006), depressive symptoms were associated with increased consumption of sweets and disordered eating patterns, such as skipping meals among depressed school children. Thus, children in distraught households become stressed emotional eaters as a result of maladaptive coping skills and develop learned behaviors through observation and socialization in their families and communities. In addition,

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parents influence children’s eating patterns through food availability and food micro-managers, such as regulating what the child eats and how much. Research has shown that the probability of being obese is associated with the layout of the community. Families residing in safe communities, with low prevalence of crime, not only have greater access to fruits and vegetables, but are physically healthier. Individuals who live in high crime rate and high illegal substance communities have poorer health conditions due to limited access to open space as well as limited fresh produce (Committee on Environmental Health, 2009). The dominant factors that shape health and health disparities among low-income populations and communities are the disproportionate social and economic determinants that negatively affect the health outcomes of individuals, in terms of prognosis and treatment. To improve health status and equity among all communities, appropriate prevention and interventions are necessary to address and combat childhood obesity. As childhood obesity continues to rise among low-income households, the U.S. witnessed an increase in public health strategies, campaigns, and programs within the past few decades. Through community-, school-, and family-based interventions, health care professionals are promoting healthy food selections and physical activity. As with most federally funded programs, low-income households and communities are the primary targeted population for childhood obesity prevention and reduction. Therefore, it is important for health care professionals to address childhood obesity through a community approach. Though family interventions are equally important, it is essential for health care professionals to advocate and address childhood obesity on all three levels of practice (micro, mezzo, and macro), as they work with individuals, families, groups, organizations, and communities. Through community-based interventions and public education, health care professionals are able to highlight environmental changes that would improve health outcomes in high-risk communities. Successful prevention and intervention programs should emphasize educational collaboration and involvement among parents, schools, and health care providers.

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As health care professionals, social workers are able take a familial and environmental approach to the treatment of obese children. The environments for children should include, but should not be limited to, the home, child care settings, schools, communities, recreational facilities, and infrastructure. Thus, health care professionals in inpatient-, outpatient-, community-, and school-based agencies, need to be active participants and advocates in health promotion and education, as well as in program implementation and evaluation. For instance, health care professionals working within the family system can influence behavioral changes by providing families the necessary nutritional education and skills. According to Golan & Weizman (2001), nutritional education is essential to all weight-loss and healthy-food-choice programs. Therefore, health care professionals can educate families on the health benefits of healthy food choices and facilitate healthyeating practices, such as reading food labels, preparing healthy, balanced meals, and physical activity. Through collaboration between health care professionals and families, behavioral changes can lead to increased self-efficacy. By helping families find solutions and treatments that are specifically tailored to their goals, parents and children will believe that they are capable of performing changes and will not be hesitant about their abilities when faced with obstacles in the future. In addition, health care professionals can advocate for childhood obesity prevention and interventions on a macro-level practice through policy reformation and program evaluations. Through program analysis and evaluation, health care professionals can adequately determine whether or not federally, state, and/or privately funded programs are effectively addressing childhood obesity. Likewise, health care professionals are experts on community resources, and advocates for school-based nutrition programs and community safety and physical health promotions.
CHALLENGES AHEAD

Over the last decade, many states have enacted legislation in support of school and community-based programs and have shown positive results in preventing and reducing obesity among children. School-based programs and efforts have focused on improving

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the quality of food, including: regulating the quality of foods sold in school cafeterias and vending machines and providing free or reduced-cost breakfast for students (Levi, Vinter, Richardson, St. Laurent, & Segal, 2009). The Maryland Meals for Achievement (MMFA) is a pilot program that offers breakfast to every student regardless of their family income; the results show a decrease in tardiness by eight percent and of suspensions by 36 percent (Levi et al., 2009). Despite the positive outcomes and efforts in preventing and reducing the childhood obesity epidemic, obesity rates will most likely continue to increase at a substantial rate due to the economic downturn. The USDA projected a five percent increase in food prices in 2009, making nutritious foods increasingly out of reach for not only low-income families, but middle-income families as well (Levi et al., 2009). Between December 2007 and May 2009, the unemployment rate increased from 4.9 percent to 9.4 percent. As of November, 2009, the unemployment rate in the U.S. was approximately 10 percent (Labor Force Statistics, 2009). Due to the economic recession, many children are no longer able to receive health and wellness services as a result of parents losing employer-sponsored health insurance. As the unemployment rate continues to rise, more Americans will be living in poverty, which could have significant implications for the obesity rate. Thus, healthy eating and food selection will become less of a priority in comparison to housing. While the majority of restaurants are struggling to survive, the fast food industry continues to thrive during the recession. Owners of fast food chain restaurants, such as Kentucky Fried Chicken and Taco Bell, reported worldwide sales growth of seven percent in 2008. Similarly, McDonald’s sales in the U.S. grew 4.5 percent in November 2008, and global sales were up 7.7 percent (Levi et al., 2008). Unable to afford fresh produce, middle-income and low-income families often have to look to less expensive food options, which are often high in calories and fat. In addition, health and wellness programs (school- and community-based) have been eliminated or have witnessed a

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reduction in federal and state funds. The current economic conditions have pushed more Americans to seek help from federal and state safety net programs, including SNAP and Medicaid. Even if Americans’ increased dependency on federal and state assistance programs results in further challenges and burdens, opportunities are available to the public despite the economic downturn. Although the current economy has had a deleterious impact on the health and wellbeing of many Americans, there are still opportunities for positive change in preventing childhood obesity. On February 14, 2009, Congress passed the American Recovery and Reinvestment Act (ARRA), an economic stimulus package that included $1 billion to support evidence-based clinical and community-based prevention (State and Territory Summaries, 2009). Through the ARRA, states are able to use the funding to create safe community places for physical activity, accessible means of transportation, school renovations, and program expansions. As childhood obesity continues to be a serious problem in the U.S., health care professionals must be aware that many programs are not adequately funded by the states. Thus, it is important for health care professionals to be aware of the available policies, programs, and community resources, so that they can become better advocates for reducing childhood obesity. In addition, health care professionals must collaborate with other professionals, including pediatricians, health care providers, program analysts, and researchers to make childhood obesity a higher priority in health reform.

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REFERENCES Alaimo, K., Olson, C., & Frongillo, E. (2001). Low family income and food insufficiency in relation to overweight in US children. American Medical Association,
155, 1161-1167.

Blisard, N., Stewart, H., & Jolliffe, D. (2004). Low-income households’ expenditures on fruits and vegetables. United States Department of Agriculture, 833, i-27. Centers for Disease Control and Prevention. (2009). Retrieved December 2, 2009, from www.cdc.gov/. Centers for Disease Control and Prevention. (2009). Overweight and obesity. Retrieved December 6, 2009, from www.cdc.gov/obesity/childhood. Committee on Environmental Health. (2009). The built environment: Designing communities to promote physical activity in children. American Academy of Pediatrics,
123, 1591-1598.

Cook, J., & Frank, D. (2008). Food security, poverty, and human development in the United States. New York Academy of Sciences, 1425, 1-17. Dong, D., & Lin, B.H. (2009). Fruit and vegetable consumption by low-income Americans.
United States Department of Agriculture, 70, ii-17.

Drewnowski, A., & Specter, S.E. (2004). Poverty and obesity: The role of energy density and energy costs. American Society for Clinical Nutrition, 79(6), 6-16. Edmund, E. (2006). A very brief history of obesity. Longboat Key News. Page 2B. Gibson, E. (2006). Emotional influences on food choice: Sensory, physiological and psychological pathways. Physiology & Behavior, 89, 53-61. Golan, M., & Weizman, A. (2001). Familial approach to the treatment of childhood obesity: Conceptual model. Society for Nutrition Education, 33(2), 102-107. Hayden, S., & Blisard, N. (2008). Are lower income households willing and able to budget for fruits and vegetables? United States Department of Agriculture, 54, ii-23. Hitti, M. (2009). How fat is your state? WebMD Health News. Retrieved November 18, 2009, from www.webmd.com/diet/news/20090708/how-fat-is-your-state. Labor force statistics from the current population survey. (2009). United States Department of
Labor. Retrieved December 5, 2009, from http://www.bls.gov/CPS/.

183

Levi, J., Vinter, S., Richardson, L., St. Laurent, R., & Segal, L. M. (2009). F as in fat: How obesity
policies are failing in America. Retrieved December 10, 2009,

from healthyamericans.org/reports/obesity2009/Obesity2009Report.pdf. Nord, M., Andrews, M., & Carlson, S. (2009). Household food security in the United States, 2008. United States Department of Agriculture, 83, ii-58. Prevention Institute. (2009). Health equity and community health. Retrieved December 7, 2009, from www.preventioninstitute.org/chhd_projects.html. St. Vincent Health. (2006). Obesity and cardiovascular disease. Retrieved December 5, 2009, fromwww.stvincent.org/healthinformation/content.htm?PageID=P00230. State and territory summaries. (2009). Recovery.gov. Retrieved December 5, 2009, from www.recovery.gov/Transparency/StateSummaries/Pages/statesummary. aspx?StateCode=CA. Streib, L. (2007). World’s fattest countries. Forbes Magazine. Retrieved November 18, 2009, from www.forbes.com/2007/02/07/worlds-fattest-countries-forbeslife-cx_ ls_0208worldfat.html. Supplemental Nutrition Assistance Program. (2009). United States Department of Agriculture. Retrieved December 5, 2009, from www.fns.usda.gov/snap/government/ program-improvement.htm. Torres, S., & Nowson, C. (2007). Relationship between stress, eating behavior, and obesity.
Nutrition, 23, 887-894.

Townsend, M.S. (2006). Obesity in low-income communities: Prevalence, effects, a place to begin. American Diabetic Association, 34-37. United States Department of Agriculture (2009). Food security in the United States:
Measuring household food security. Retrieved December 7, 2009, from

www.ers.usda.gov/Briefing/FoodSecurity/measurement.htm. U.S. Department of Health & Human Services. (2009). Overweight and obesity: Health
consequences. Retrieved December 8, 2009, from www.surgeongeneral.gov/topics/

obesity/calltoaction/fact_consequences.html.

184

Wang, Y., Liang, H., Tussing, L., Braunschweig, C., Caballero, B., & Flay, B. (2007). Obesity and related risk factors among low socio-economic status minority students in Chicago.
Public Health Nutrition, 10(9), 927-938.

World Health Organization. (2009). Retrieved December 5, 2009, from www.who.int/dietphysicalactivity/childhood/en/. World Health Organization Report. (2009). Why does childhood overweight and obesity matter? World Health Organization. Retrieved December 4, 2009, from www.who.int/ dietphysicalactivity/childhood_consequences/en/index.html. Zastrow, C., & Kirst-Ashman, K. (2007). Understanding human behavior and the social
environment (7th Ed.) Belmont, CA: Thomas Learning, Inc.

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